Reducing Inequities in Health and Safety Through Prevention
Feature article provided by the Prevention Institute and the Health Policy Institute at the Joint Center for Political and Economic Studies
"Simply put, in the absence of a radical shift towards prevention and public health, we will not be successful in containing medical costs or improving the health of the American people."
Barack Obama has stated: “We’re going to have some very aggressive initiatives…around things like prevention that reduce costs.”2 We applaud the growing recognition across Congress, within the new Administration, and among the American people that prevention can and must be part of the solution to reform the US health system. Prevention is crucial to improving health and reducing inequities between racial, ethnic, and socioeconomic groups. Strategic investment and implementation of prevention strategies can address the underlying conditions that lead to death, illness, injury, and health inequities in the first place.
Effective prevention initiatives save lives, reduce misery, stimulate the economy, and save money. As the US population is projected to become even more diverse in coming years, achieving a healthy and productive nation will increasingly rely on our ability to keep all Americans healthy. Now is the time to invest significantly in prevention to reduce racial, ethnic, and economic inequities.
This article offers our suggested strategy for developing a comprehensive, prevention-oriented approach to health equity, building upon related thinking such as that expressed in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care3 and Promoting Health: Intervention Strategies from Social and Behavioral Research4 by the Institute of Medicine and Blueprint for America by Trust for America’s Health,5 as well as PolicyLink’s work on health and place6 and the Institute for Alternative Future’s Disparity Reducing Advances project.7
The article begins with a discussion of existing health inequities, and then explains the value of prevention in helping reduce inequities. It includes a description of the two steps back framework, which identifies and addresses the determinants of health and health inequalities and the value of an investment in prevention. The article then provides a structured path for change, starting with the highest levels of the federal government and continuing to states and communities. We offer strategies that can be implemented in the short term through vehicles such as the economic stimulus package, as well as those that can be integrated into longer-term action.
Every year, hundreds of thousands of people die in the United States from preventable illnesses and injuries.8,9 These illnesses and injuries disproportionately impact communities of color and lower wealth communities.10 Low-income populations and people of color do not experience different injuries and illnesses than the rest of the population; they suffer from the same injuries and illnesses, only more frequently and severely. For example:
- Compared to Whites, American Indians and Alaska Natives are 2.3 times more likely to have diagnosed diabetes, African Americans are 2.2 times more likely, and Latinos are 1.6 times more likely.11
- Among African Americans between the ages of 10 and 24, homicide is the leading cause of death. In the same age range, homicide is the second leading cause of death for Hispanics, and the third leading cause of death for American Indians, Alaska Natives, and Asian/Pacific Islanders.12 Homicide rates among non-Hispanic, African-American males 10-24 years of age (58.3 per 100,000) exceed those of Hispanic males (20.9 per 100,000) and non-Hispanic, White males in the same age group (3.3 per 100,000).13
- Native Americans have a motor vehicle death rate that is more than 1.5 times greater than Whites, Latinos, Asian/Pacific Islanders, and African Americans.14,15
- Poverty is associated with risk factors for chronic health conditions, and low-income adults report multiple serious health conditions more often than those with higher incomes.16
- The average annual incidence of end-stage kidney disease in minority zip codes was nearly twice as high as in non-minority zip codes.17
- Premature death rates from cardiovascular disease (i.e., between the ages of 5 and 64) were substantially higher in minority zip codes than in non-minority zip codes.18
- Education correlates strongly with health. Among adults over age 25, 5.8% of college graduates, 11% of those with some college, 13.9% of high school graduates, and 25.7% of those with less than a high school education report being in poor or fair health.19
Further, data is collected for large statistical groups hiding many of the real inequities that exist in the population. Once the data is disaggregated, a more accurate picture of disparities within ethnic groups emerges. For instance, Asian Americans are not a homogeneous group: nationally, Vietnamese-American women have the highest rates of cervical cancer, with incidence rates estimated at five times higher than White women.20
Each year, our nation spends over two trillion dollars on health expenditures and approximately 96%of this is expended on medical services—treatment after the onset of illnesses and injuries.21 Much of the national discussion and research on health disparities has focused on differences in access to quality health care. Once people get sick or injured, affordable quality health care is vital, and some inequities in health outcomes are due to disparities in access to and quality of care, such as those documented in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.22 Nevertheless, access to health care only accounts for 10% of the variation in morbidity and mortality; other factors that determine health include environments and behaviors.23 Issues of inequity in medical care are covered elsewhere; this memo focuses on understanding what happens prior to the onset of illness and injury to create inequitable outcomes.
Advancing health equity to ensure all Americans have the opportunity to lead healthy lives should be a priority. We have an opportunity to do so in a way that alleviates pressure on the health system and saves money. The Prevention Institute and the Health Policy Institute at the Joint Center for Political and Economic Studies developed this memo in January ’09 to provide background and recommendations for achieving equitable health outcomes for all.
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1 Obama ’08. Barack Obama’s Plan for a Healthy America: Lowering health care costs and ensuring affordable, high-quality health care for all. Available at: www.barackobama.com/pdf/HealthPlanFull.pdf
2 The Office of The President-Elect. December 11, 2008. Available at: http://change.gov/newsroom/
3 Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; 2002.
4 Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC: National Academy Press; 2000.
5 Trust for America’s Health. Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness. Oct 2008. Available at:
6 PolicyLink. Center for Health and Place. Available at: www.policylink.org/HealthAndPlace/
7 Institute for Alternative Futures. The Accelerating Disparity Reducing Advances. Available at:
8 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.
9 McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212.
10 United States Department of Health and Human Services. National Center for Health Statistics. Health,
United States, 2006. Washington, DC: U.S. Department of Health and Human Services; 2007.
11 Centers for Disease Control and Prevention. Health United States, 2007. Table 55. 2007. Available at: www.cdc.gov/nchs/data/hus/hus07.pdf
12 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Webbased Injury Statistics Query and Reporting System (WISQARS). Feb 2006. Available at: www.cdc.gov/ncipc/wisqars.
13 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Youth Violence. Available at: www.cdc.gov/ncipc/dvp/YV_DataSheet.pdf
14 United States Department of Transportation. National Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999 – 2004. May 2006. Available at:
15 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Webbased Injury Statistics Query and Reporting System (WISQARS). Available at: www.cdc.gov/ncipc/wisqars.
16 National Center for Health Statistics. Health, United States, 2007 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: U.S. Department of Health and Human Services; 2007.
17 National Minority Health Month Foundation. Study of Vital Statistics by ZIP Code Shows Health Disparities Affecting Minorities in the Treatment of Kidney and Cardiovascular Diseases. March 2007. Available at: www.rwjf.org/publichealth/product.jsp?id=18669.
18 National Minority Health Month Foundation. Study of Vital Statistics by ZIP Code Shows Health Disparities Affecting Minorities in the Treatment of Kidney and Cardiovascular Diseases. March 2007. Available at: www.rwjf.org/publichealth/product.jsp?id=18669.
19 National Health Interview Survey 2001-2005, available at www.cdc.gov/nchs/nhis.htm
20 Miller BA, Kolonel LN, Bernstein L, et al, eds. Racial/ethnic patterns of cancer in the United States, 1988-1992. Bethesda, MD: National Cancer Institute; 1996.
21 Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. 2006 National Health Care Expenditures Data. January 2008. Available at:
22 Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; 2002.
23 Lee P and Paxman D, Reinventing Public Health. Annual Review of Public Health, 1997; Vol. 18: 1-35.