Health Disparities, Health Inequities, and Social Determinants of Health

See the 2010 Health Disparities Report Card

Health disparities are a serious concern nationally, as well as in the City of Baltimore.  Health disparities are “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.”1  For example, differences in health outcomes between racial/ethnic groups, between men and women, between people with different levels of income or education, or between neighborhoods would all be considered health disparities.  The following are some examples of health disparities in Baltimore:

• The all-cause mortality rate for Blacks is 1.33 times higher than that for Whites (2007)2
• The all-cause mortality rate for Men is 1.59 times higher than that for Women (2007)2
• The all-cause mortality rate for residents (ages 25 and over) with a high school education or less is 2.34 times higher than that for residents with at least some college (2007)3

• The average life expectancy of residents in the Hollins Market community is 20 years less than that for residents in the Roland Park community (2008)4

Health disparities are called health inequities when they are the result of unfair and systematic social, political, economic, and environmental policies and practices.  Health inequities are thus those subset of health disparities that are unjust and avoidable.  These inequities stem from the inequitable distribution of the social, economic, and political resources, power, and opportunities that promote and enhance health.  These health promoting and enhancing resources and opportunities are called social determinants of health, and include things like access to healthy food, healthy housing, healthcare, safe neighborhoods, education and employment opportunities, and transportation.

The role of social determinants of health in shaping health inequities is gaining more attention nationally and internationally.  The World Health Organization states, “the social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities”.5  Limited access to and control over these social determinants of health by certain groups results in health inequity.  Health equity, then, is when all people, regardless their social position or grouping, have equitable access to the resources and opportunities necessary for promoting and preserving health throughout their lifecourse.

“Inequity in the conditions of daily living is shaped by deeper
social structures and processes. The inequity is systematic,
produced by social norms, policies, and practices that tolerate
or actually promote unfair distribution of and access to power,
wealth, and other necessary social resources.

Every aspect of government and the economy has the
potential to affect health and health equity – finance, education,
housing, employment, transport, and health, just to name six.
Coherent action across government, at all levels, is essential
for improvement of health equity.” 

Commission on the Social Determinants of Health8

The Baltimore City Health Department Health Disparities Initiative

The Baltimore City Health  Department’s Health Disparities Inititiative (HDI) was launched in recognition of the significant impact that health disparities have in Baltimore communities.  The 20-year life expectancy disparity between certain communities in Baltimore is driven largely by disparities in cardiovascular disease (CVD), which includes heart disease and stroke—the No. 1 and No. 3 killers in Baltimore.  There are also large disparities in diabetes, obesity, and hypertension, which are risk factors for CVD.  The following are examples of health disparities related to CVD in Baltimore:

• The stroke mortality rate for Black women is 1.58 times higher than that for White women; stroke mortality for Black men is 1.43 times higher than that for White men (2007)2
• The diabetes mortality rate for Blacks is 1.71 times higher than that for Whites (2007)2
• The heart disease mortality rate for residents (ages 25 and over) with a high school education or less is 2.29 times higher than that for residents with at least some college (2007)3

• 46% of Black residents reported being told they have high blood pressure, compared to 23% of Whites (2007)6

• Residents in the lowest income level (<$15,000) are 4 times more likely to report being obese than residents in the highest income level (>=$75,000)6
• The heart disease mortality rate in the Druid Park/Upton community is 2.87 times higher than that in the North Guilford/Homeland community (2007)7

In light of these troubling disparities, a CVD Agenda was developed as the initial and primary component of the Health Disparities Initiative.  The Agenda was launched by Mayor Sheila Dixon, Rep. Elijah E. Cummings, and State Delegate Shirley Nathan-Pullian on April 15th 2009 in an effort to reduce the impact of CVD in Baltimore City.  The Agenda consists of community-based education, screening, and outreach strategies that are targeted to improve awareness, prevention,  and management of CVD in the most affected communities in the City.  More information on the CVD Agenda can be found here.

The CVD Agenda is an initial component of a growing impetus at BCHD to resolve the issue of health disparities in the City.  BCHD is becoming increasingly more in tune with the role that social determinants play in shaping health disparities.  As both capacity and momentum grow, the Health Disparities Initiative will evolve and expand to ensure that social determinants remain a focal point, and that all decisions, actions, and programs are rooted firmly in a health equity framework.  BCHD will continue to support elements of the HDI, including the CVD Agenda and similar initiatives, in its ongoing and growing effort to achieve health equity for all Baltimore City residents and communities—Because all communities keep the heart of Baltimore beating.

SOURCES:

• National Institutes of Health (NIH). 2005. Addressing disparities: the NIH program of action. What are health disparities?
• BCHD analysis of 2007 Maryland Vital Statistics Profile data and CDC Wonder (Vintage 2007) bridged-race population estimates.  Rates age-adjusted to 2000 Census standard population, distribution #1.
• BCHD analysis of 2007 Maryland Vital Statistics Profile data and 2007 American Community Survey (ACS) 1-year population estimates.  Rates age-adjusted to 2000 Census standard population, distribution #11.
• BCHD Neighborhood Health Profiles, 2008: www.baltimorehealth.org/neighborhood.html   
• World Health Organization, Social Determinants of Health program: www.who.int/social_determinants/en/
• Maryland Behavioral Risk Factor Surveillance Survery (BRFSS), 2007:  http://fha.maryland.gov/ohpp/brfss.cfm
• BCHD analysis of 2000-2007 Maryland Vital Statistics Profile data and 2000 Census data.  Rates age-adjusted to 2000 Census standard population, distribution #1.
• Commission on the Social Determinants of Health (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.

  Community Action Toolkits

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Heart Disease and Diabetes programs are happening all over Baltimore City. The Baltimore City Health Department is promoting screenings, referrals and disease management interventions to reduce the risk and burden of heart disease. Find out what’s going on in your neighborhood to take the next step in fighting our City’s leading cause of death. If you know of additional resources that should be listed here, please contact Kay.Sibetta@baltimorecity.gov or call at 443-984-4098.