By Alvaro Carrascal, MD, MPH
These days we hear a lot about health disparities, cancer disparities, health equity, etc. What is this all about? And why do these terms seem to be more discussed now?
MedlinePlus, the National Institutes of Health's website for patients, describes health disparities as "differences between groups of people. These differences can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death."
For the World Health Organization (WHO), health equity is "the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically."
Essentially, health equity is about everyone getting a fair shake when it comes to health and healthcare.
So let's see what that means in the real world. If we look at the numbers, we'll see that cancer is not equally distributed across the population. For example:
- Hispanic women have the highest proportion of new cases for cervical cancer among all ethnic/racial groups.
- African Americans are more likely to develop cancer than any other racial or ethnic group.
These differences are not limited to racial and ethnic categories. If we consider education and income, there are differences in risk factors (factors that increase the chance of developing cancer) among groups. For example:
- Between 2000 and 2010, New York saw significant reductions in smoking across all racial/ethnic groups; however, among those with some or no high school education and low income there were no reductions at all.
- Nationwide, individuals with less than high school education are twice as likely to smoke as those with college/graduate school education.
If we look at who gets screened for cancer, we see differences again:
- Poor women get mammograms at 2/3 the rate of middle/high income women.
- The uninsured (a group that includes predominantly Latinos, recent immigrants, and the working poor) are screened for colorectal (colon) cancer at rates that are half of those with insurance.
- Privately-insured individuals are more likely to be screened for colon, breast, and cervical cancer than those publicly-insured (Medicaid, Medicare)
And there are differences in deaths from cancer:
- African Americans have higher death rates for all major cancers (e.g. colon, lung, breast, prostate, etc.).
- Individuals with no health insurance are more likely to be diagnosed with advanced cancer, which is harder to treat, and they are less likely to receive standard care and survive.
- Across all racial and ethnic groups, people who are the poorest have shorter survival after a cancer diagnosis. (This is true among whites or blacks or Asian Americans, etc.)
- Lung cancer deaths are 4 to 5 times higher in the least educated vs. the most educated people.
- Death rates for kidney cancer in American Indian and Alaska Native men and women are higher than in any other racial or ethnic population.
Achieving health equity
These facts show that health disparities are not only due to racial/ethnic differences. They are mainly the result of lack of education, poverty, access to health care, and other socio-economic factors. These are what the WHO calls "social determinants of health" - and they are key factors in health equity.
We don't have health equity because we still have so many people struggling to get an education, escape poverty, and deal with all the other factors that prevent them from adopting healthy behaviors --and getting the care they need.
These problems are not new. So why do we hear more now about "health equity?"
In 1985, the US Department of Health and Human Services issued the Report of the Secretary's Task Force on Black and Minority Health, documenting "health disparities" across the nation and the term became more widely used in the early 1990s. In 1995, the WHO started a global initiative on Equity in Health and Health Care. Since then the term "health equity" has been increasingly used both in the United States and abroad. Health equity is associated with fairness and justice. It implies a commitment to ensure that health is equally distributed by addressing the social determinants. In the most comprehensive effort to promote health equity, in 2011, the U.S. government released a National Stakeholder Strategy for Achieving Health Equity that laid out strategies for fighting health disparities.
The State of the Health Equity Movement, 2011 Update, produced by the Institute for Alternative Futures, reports that between 2009 and 2011 the number of health equity initiatives undertaken by U.S. organizations, foundations and government institutions grew from 60 to 159.
These initiatives recognize that national, state, and local policies can influence those "social determinants of health" in ways that can help achieve health equity.
The American Cancer Society also has long recognized that policy decisions impact the fight against cancer. That's why the Society's non-profit, non-partisan affiliate, the American Cancer Society Cancer Action Network (ACS CAN), fights for increased access to health care through measures like the Affordable Care Act and the National Breast and Cervical Cancer Early Detection Program, which funds cancer screenings tests for low-income women. It also fights for clean air laws that can reduce the number of people exposed to tobacco smoke, a leading cause of cancer and other illnesses.
A long-term commitment
But, let's be realistic. The disparities can't be erased overnight. Achieving health equity will be a long process that will require steps and real input from many partners and stakeholders, even beyond the health sector, in many different fronts and at different levels. Long term commitments to increase education levels, create better and healthier living environments, and improve socio-economic conditions across the board will be needed to get us to a place where everyone could attain their full health potential.
At the American Cancer Society, we're taking this seriously.
Beyond advocating for sound public policy decisions with ACS CAN, the American Cancer Society is investing in research to learn more about cancer disparities and find more effective ways to reduce or eliminate them. We're partnering with other organizations and stakeholders to increase awareness, and engaging and empowering underserved communities to take steps toward better health. Leadership, community empowerment, partnerships from multiple sectors, and research and evaluation are the keys to getting closer to a day in which health equity would be a reality for all.
For more on cancer disparities, please see the special section in Cancer Facts & Figures 2012.
Dr. Carrascal is the senior vice president of cancer control for the American Cancer Society Eastern Division.