National Association of County and City Health Officials, 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 opportunities.

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 disparities.

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 justice.

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.