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Health is Not an Equal Opportunity

Jan MalcolmWe Minnesotans are proud of our high rankings among the states on many measures, including economic growth and prosperity, educational attainment, and health. However, those high rankings are about averages, and they conceal some of the worst disparities in the nation on the same measures.

Researchers at the Minnesota Department of Health (MDH) and elsewhere have been aware of stark differences in health outcomes for some populations—for decades. The public health and health care communities have made efforts to respond, but largely feel as though we have been "running in place."

Under Commissioner Ed Ehlinger's leadership, MDH issued a remarkable report to the legislature in 2014 called Advancing Health Equity in Minnesota. The report again detailed the extent of disparities among various populations and connected causes to underlying community conditions. The bottom line is that we have these disparate outcomes because the opportunity to be healthy is not equally available everywhere or for everyone in our state. The report's findings include:

  • African American and American Indian babies die in the first year of life at twice the rate of white babies. While infant mortality rates for all groups have declined, the disparity in rates has existed for over 20 years.
  • American Indian, Hispanic/Latino, and African American youth have the highest rates of obesity.
  • African American and Hispanic/Latino women are more likely to be diagnosed with later-stage breast cancer.
  • Gay, lesbian, and bisexual university students are more likely than their heterosexual peers to struggle with their mental health.
  • Persons with serious and persistent mental illness die, on average, 25 years earlier than the general public.

These health disparities persist and are neither random nor unpredictable. We know so much more now about what truly creates health, far beyond insurance coverage and access to clinical care, important as those are. The groups that experience the greatest disparities in health outcomes also experience the greatest inequities in the social and economic conditions that are such strong predictors of health:

  • Poverty rates for children under 18 are twice as high for Asian children, three times as high for Hispanic/Latino children, four times as high for American Indian children, and nearly five times as high for African American children as for white children.
  • Unemployment is highest among populations of color, American Indians, and people who live in rural Minnesota.
  • While 75 percent of the white population in Minnesota owns their own home, only 21 percent of African Americans, 45 percent of Hispanic/Latinos, 47 percent of American Indians, and 54 percent of Asian Pacific Islanders own their own homes.
  • Gay, lesbian, bisexual, and transgender youth are at increased risk of bullying, teasing, harassment, physical assault, and suicide-related behaviors compared to other students.
  • American Indian, Hispanic/Latino, and African American youth have the lowest rates of on-time high school graduation.
  • African Americans and American Indians are incarcerated at nine times the rate of white persons.

The MDH report is clear that the barriers to equal opportunity for optimal health are structural. It was bold in speaking explicitly about the relationship of race to structural inequities. All leaders in the health and health care sector are challenged first to see, and then work to address, the structural racism that is deeply embedded in our history, our society, and our institutions. Structural racism is defined as "the normalization of an array of dynamics that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color and American Indians. It is perpetuated when decisions are made without accounting for how they might benefit one population more than another, or when cultural knowledge, history, and locally generated approaches are excluded."

The report contains many practical recommendations for public health, health care, and other community partners, with references to evidence and national best practices. As we move farther upstream to improve community conditions, we will reap the benefits of closing other gaps—in education, employment, and economic stability. This "virtuous cycle" of improvement can help fuel even greater improvements in population health, while bringing our national health care expenditures closer in line to those of our global peers (and economic competitors). I can't think of a more worthy project for our collective efforts.

Jan Malcolm is a member of the Stratis Health Board of Directors. She is Commissioner of Health for the State of Minnesota and an adjunct faculty member at the University of Minnesota School of Public Health.