National Association of County and City Health Officials  [Printer-friendly version]
March 20, 2002


Testimony on behalf of The National Association of County and City
Health Officials, before The Institute of Medicine on the Creation of
an Annual Report on Health Disparities, Washington, D.C.

We have reached a point in human history when the excuses for the
absence of an equitable society in our nation have been raised to a
new level of contradiction. Here in this, the richest nation in the
history of mankind, here in a society where medical technology has
reached Star Trekean heights, here where replaceable organs are common
place, where we have the technology to clone life itself and have
discovered the secret of nature's blue print through the Human Genome
Project, we continue to grapple with the most basic of human rights,
the right to health, health care and life itself. According to
results, we continue to accept a paradigm of existence that relegates
entire groups of people who look different, are of a different color,
speak different languages, and find themselves trapped in a cycle of
poverty seemingly without end, to shorter lives troubled by poorer
health and blocked access to equity and equal access to society's

These are not new revelations. W.E.B. Dubois documented the gap in the
health of African Americans and whites in his landmark work "The
Philadelphia Negro" at the turn of the 20th century. In the 1920's,
Booker T. Washington began an organized focus on this very issue by
organizing an equal health movement at Clark University. The recent
work of Dr. E. Michael Byrd and Dr. Lynda Clayton chronicle the
foundations of these disparities, the inequities in the health of
African Americans, dating back to the 1600's and the foundations of
today's "slave health deficit." Further, we acknowledge the growing
gap in per capita income, the widening gap between the haves and the
have nots, and an increasing appreciation for the social determinants
of health. We place particular emphasis on the chronic effects of
racism, both individually mediated and institutionalized. With this
basic introduction of themes too often left silent and in the name of
the National Association of County and City Health Officials, I, Dr.
Adewale Troutman, thank the Institute of Medicine for the opportunity
to testify today on this matter of critical importance.

Its importance is not limited to the lives of those that suffer and
die before their expected time but in fact is a statement on the very
humanity of this nation. How civilized are we when African American
infants continue to die at rates greater than twice that of white
babies. How advanced are we when there are major urban centers where
African American men have a life expectancy of 61.5. No, in fact, the
very nature of what we see as civilization dictates that just as sure
as we are that there is a thing known as universal principle, there
must be social justice that guarantees health equity.

As public health professionals, NACCHO -- the organization that
represents the nation's over 3,000 local health departments --
champions the principle of social determinants of health and believes
in the creation of health equity through social justice. We believe in
the World Health Organization's definition of health that states that
health is not merely the absence of disease but the presence of
physical, social, psychological, and spiritual well being. Further, we
acknowledge the preamble of the constitution of the WHO, which states:
"The enjoyment of the highest standard of health is one of the
fundamental rights of every human being without distinction of race,
religion, political belief, economic or social condition." We believe
in the words of the Alma-Ata Declaration made at the International
Conference on Primary Health Care that "the right to health is the
most important social goal." Further, we affirm the International
Declaration of Human Rights that "everyone has a right to a standard
of living adequate for the health and well being of himself and his
family including food, clothing, housing, and medical care."

Centuries of work on these issues, including the recent pressure
fostered by the Congressional Black Caucus, have led to the race
initiative's inclusion of health disparities as a major focus of the
Clinton administration; the work of former Surgeon General David
Satcher; and the single goal focus of Healthy People 2010, where for
the first time separate goals for African Americans, minorities and
whites no longer exist, but rather a single set of goals for all that
we as a nation either meet or fail to meet.

These goals are an important step, but the extent to which they focus
only on the life style issues of populations and their personal
behaviors is the extent to which they cannot succeed. Healthy People
2010 addresses the need to eliminate health disparities, but these
disparities are rooted in societal inequities manifested through
institutional racism, income gaps, entrenched poverty, and social
injustice. We at NACCHO accept the cause and effect of social
determinants of health. In that vein, studies in the United States
conducted by the Census Bureau indicate that the level of income
inequality fell by approximately 9% from 1947 to its postwar low in
1969, but has since grown by at least 25%, reaching a postwar high in
1993 and 1994 and remaining stable since then. As a result, income
inequality in the American economy now surpasses that of any other
advanced industrialized country. Findings by Peter Arno and Janis
Figueroa in their work entitled "The Social and Economic Determinants
of Health" are supported by Vincente Navarro's article in the Lancet,
"Assessment of the World Health Report 2000," where he writes:
"Published literature shows that much of the widening gap in mortality
rates within and among countries is primarily related to the growing
differentials in wealth and income," and further that during the 20th
century "the most dramatic changes in mortality were the result of
social and economic interventions."

As compelling as the arguments are that focus on socioeconomic
disparities and health, it is impossible to have a frank discussion of
inequality without confronting the continuing blight of racism head
on. In many ways, the central issue is that long established and
growing health disparities are rooted in fundamental structural
inequalities bound up with the racism that continues to pervade US
society. We seem to think that health and health care have somehow
escaped the history that has affected every other institution in the
United States; that is, a history filled with negative race
consciousness and both covert and overt racism. It is to be remembered
that a leading cause of death at the turn of the century for African
Americans was lynching, and that it was medical pseudo-science that
laid the foundation for Jim Crow legislation in this country by
preaching that Blacks were genetically unclean.

The work of Dr. Camara Jones defines three levels of racism:
institutionalized, personally mediated, and internalized. When coupled
with the recent studies of provider attitudes towards people of color
and women in general one sees a scenario where according to Jones
there is a "differential access to goods, services and opportunities
of society by race." Further, that "it is structural, having been
codified in our custom, practice and law so that there need not be an
identifiable perpetrator." However, the combination of an
institutional bias, provider attitudes that suggest racial
interpretation to population based ideas of inferiority, and an
internalized process of self devaluation and hopelessness; coupled
with the undeniable effects of poverty, socioeconomic inequity, and
the absence of social justice; and we have a guarantee of early death,
markedly decreased quality of life, increased morbidity and mortality
and the marginalization of millions and millions of humans endowed by
their creator to certain inalienable rights such as life, liberty and
the pursuit of happiness.

Dr. David Williams, in his work "The Concepts of Race and Health
Status in America," captures my thinking on the current focus on risk
behaviors among populations with these identified disparate health
outcomes. He states that, "there is a temptation to focus on
identified risk factors as the focal point for intervention efforts.
In contrast, we indicate the macrosocial factors and racism are the
basic causes of racial differences in health." This is not to say that
we must abandon the process of risk factor identification and
amelioration, but instead recognize that as we continue to ask why in
this new logic model, we get to the root causes of the current picture
of ill health of large segments of our population: social injustice,
economic inequity, and racism. Where short- term solutions to improve
lifestyle choices are in order, long-term solutions designed to bring
about health equity through social justice are the definitive answer
to the nation's plight.

It is a belief in these principles that led NACCHO to focus on the
social determinants of health at its last national conference in 2001.
Its plenary session on the effects of institutional racism on health
outcomes spurred the development of NACCHO's national committee on
Health and Social Justice, which I have the privilege of Chairing, and
NACCHO's revision of its strategic plan to address issues of health
equity, social justice, its opposition to racism, and its support for
diversity and cultural competence.

The Institute of Medicine has been a significant force in shaping
health care policy and practice in this country. As such, we are
pleased to see the IOM focus its attention on what is one of the most
significant barriers to establishing a single standard of high quality
care and the attaining of optimal health for all, namely socioeconomic
and racial inequities. In that regard, we support the IOM's move to
design a National Disparities Report. The research and historical
wisdom make it clear that this report must focus on racial, ethnic,
geographic and socioeconomic disparities. The reports usefulness must
be tied to its ability to define solutions to these long-standing
problems. It must have the foresight and the fortitude to address the
difficult issues and the intestinal courage to make the difficult
conclusions and the even more difficult solutions and policy
directives that hold the future of health and health care in the US.

The existence of such an annual report not only gives us an
opportunity to collect and analyze sentinel data that gives a real
time look at the critical issues of social determinants of health, but
also permits us to measure our progress towards the goal of an
egalitarian society where no one is left behind because of their race,
ethnicity or socioeconomic status. This report can stand next to
Healthy People 2010, which places a greater emphasis on the individual
as a step towards the development and institutionalization of a social
health index such as the one suggested by Marc Miringoff in his book,
The Social Health of the Nation: How America is Really Doing.
Miringoff's use of some sixteen indicators to measure such factors as
family income, education, health, housing, child poverty, drug use,
and other social indicators gives us a useful tool to assess social
health on an annualized basis. As we expand the work of Dr. Jones's
"Working Group on Racism" as it seeks to develop measures of racism
both individually mediated and institutionalized, we have a reasonable
framework by which to measure our progress as a society and as a
profession towards the stated goal.

Such an IOM report should include a primary focus on the institution
that is health and health care itself. The growing body of research
that places the internalized attitudes and beliefs of the practitioner
in a critical position as it relates to health outcomes of individuals
and populations cries out for an intense look at selection and
training of practitioners, individual and institutional practices and
the broader appraisal of access to culturally competent health
professionals, institutions and policies. In the past, the nation
turned to civil rights legislation, constitutional amendments, and
hospital construction policies tied to access to care and other
examples of socially conscious public policy to address issues of
inequity in society. Perhaps we have entered another area where
practice needs assistance from policy as it relates to the acquisition
of equity in the American landscape. This provides another potential
area of focus for the proposed IOM annual report on healthcare

The state of Minnesota in its recently released state plan, "A Call to
Action: Advancing Health for All Through Social and Economic Change,"
affirmed the fact that the social and economic environment,
represented by income, education and income distribution, social
norms, social support, and community cohesion; living conditions such
as availability of affordable housing, transportation, nutritious
foods, employment, and working conditions; culture, religion, and
ethnicity; and the continuing and ongoing effects of racism, along
with individual factors are the key elements of health for populations
and society. Public health has long recognized the interrelationship
of these factors. It has championed the fact that health is
multifactorial and solutions to health inequity must address all
facets of the problem in a comprehensive and coordinated multisectoral
approach. The value of the IOM annual report then rests in its ability
to continue to provide the research and the data that further defines
these issues and more importantly becomes a living document in its
ability to provide both qualitative and quantitative conclusions to
shape policy and programs to bring about health equity through social

The National Association of County and City Health Officials is
committed to these goals and stands ready to assist the IOM in all
phases of its work in this area. Our committee on Health and Social
Justice, our Board of Directors and our membership stand for 100%
access and zero disparities and the belief that health is a right and
that we can advocate no higher calling as it relates to health than to
advocate for the creation of a society where inequity is but a bitter
memory and racism is only studied in history texts as a human
aberration, and where the health community led the charge to affirm
and support the principle that none of us are healthy if any of us
fall prematurely due to man-made obstacles derived from our beliefs,
practices or institutions. We then applaud the IOM for its work in
this area and look forward to the usefulness and the applications of
its work for the betterment of society as we eliminate health
inequities through a process of creating social justice.