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A Right to Equal Care: Health Inequalities Among People of Color

February 29, 2016

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A Right to Equal Care: Health Inequalities Among People of Color

Health disparities adversely affect groups of people who have experienced obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; or other characteristics that have historically been linked to discrimination or exclusion.

-- Healthy People 2020

The NIH defines health inequalities (or disparities) as the "differences in the ... prevalence, mortality and burden of disease ... among specific groups in the U.S." In particular, studies have shown that minority groups in the U.S. have higher rates of chronic conditions and worse health outcomes compared to whites. For example, cancer rates among African Americans are 10% higher than whites, and African Americans and Latinos are twice as likely to develop diabetes. The rate of asthma is 28% higher in African Americans than whites, and they also account for 22% of hepatitis C cases, even though they make up only 13% of the U.S. population.

Who we are and where we live matters to our health. Many factors, alone or in combination, can cause health inequalities, including poverty, location, race, ethnicity, gender, age, sexual orientation, etc.

Who we are and where we live matters to our health. Many factors, alone or in combination, can cause health inequalities, including poverty, location, race, ethnicity, gender, age, sexual orientation, etc. Overcrowded and underfunded clinics or a failure to reach vulnerable people contribute to the problem. Even if policymakers could address some of these underlying problems, health inequalities would remain in other areas. Studies show, for example, that even if we succeeded in eliminating overcrowding in clinics, it would only have a modest effect on quality of life for African Americans, who experience poor health as a group.

Substance use, sexually transmitted diseases, poverty, stigma, and discrimination make Blacks and Latinos more vulnerable to many preventable diseases, including HIV. But health is not a privilege -- it is a human right. From a public health perspective, each person should be able to achieve "full health potential" regardless of social and economic factors.

In the U.S., health inequalities often occur due to racial and ethnic differences, but elsewhere in the world it usually refers to differences arising from economic status and from being a part of certain groups. These differences are often both unfair and avoidable. For example, death rates among new mothers in the U.S. are higher among women of color than among white women, and low birth weight is more common among female newborns than among males. Better policies and interventions and the removal of barriers to health care for minorities could help address these inequalities, even if the causes of the disparities are unknown.


A Global Issue

Economic growth and well-being around the world has been threatened by the HIV epidemic. The epidemic and its related problems are especially dire in developing countries in areas where money and resources are scarce, such as sub-Saharan Africa, South Asia, and the Caribbean. Fortunately, the work of AIDS activists has made HIV treatment and medical services more available in many countries around the world, with foreign aid. Low-cost generic drugs and more effective HIV meds have greatly improved the life expectancy and quality of life of people with HIV, narrowing health inequalities.

Looking at the global HIV epidemic helps us to understand efforts to fight HIV in the U.S. For instance, sub-Saharan Africa is a region with an underdeveloped economic structure, much poverty, and low employment. But highly sophisticated and well-implemented programs have shown success in fighting the region's epidemic. These strategies are part of complex systems involving national and international funding combined with local oversight. The full participation of every stakeholder (civil society, local governments, and foreign providers) is essential to these programs' success.

The sub-Saharan epidemic is especially severe -- in Swaziland, for example, 28% of all adults are living with HIV. Most transmissions occur through heterosexual sex. Women are more vulnerable to HIV because they lack economic opportunities and as an effect of their role in society, In particular, younger women can be forced to have sex with older men for money, food, or housing. Many children have been orphaned by HIV and are at risk themselves, while there are few safety nets to help them. Using limited resources, the growth of HIV infection rates has been contained but continues to affect certain groups (MSM, sex workers, women, IV drug users) more than others. And the success of the newer programs has prolonged people's lives so that are also aging with HIV, adding more pressure to the underfunded and overcrowded health care system.

Foreign aid through PEPFAR, the Global Fund, and the U.N. accounts for more than 80% of the effective treatment of HIV-positive people in sub-Saharan Africa. But these funds are vulnerable to cuts. As quality and length of life improve due to greater access to HIV treatment, interventions that provide the best value for money are essential.

A Stubborn Epidemic

Africans Americans, Latinos, and women are at greater risk for HIV, and often have lower economic status. HIV rates for these groups are higher compared with those of Whites and Asians.

In New York City, the number of new HIV infections remains high compared with that in other U.S. cities. HIV interventions in NYC have had some success in slowing infections overall, but have fallen short when it comes to protecting minorities. Here, infections are more prevalent among certain racial/ethnic groups and those engaging in certain risk behaviors. For instance, Africans Americans, Latinos, and women are at greater risk for HIV, and often have lower economic status. HIV rates for these groups are higher compared with those of Whites and Asians. While new HIV infections remain high in NYC (2,718 in 2014), they are declining, particularly in newborns (none were born with HIV in 2014). At the same time, new infections are rising among Black and Latino males and young MSM but are falling in other groups, including IDUs and heterosexuals.

Of equal concern, survival rates five years after an HIV diagnosis vary across these groups. Whites have the highest survival rates (around 98%), while Blacks and Latinos have an average of 92%.

Being economically disadvantaged increases one's risk for HIV, leading to premature death and disability. Rates of HIV infection and deaths from HIV are higher in certain neighborhoods: Chelsea-Clinton, the south Bronx, Harlem-Morningside Heights, and Central/Southeast Brooklyn -- all neighborhoods with a majority of residents living below the federal poverty level.

The intersection of drug use and the criminal justice system is an important factor in the spread of HIV in minority groups. The prison system weakens social and family networks, and the family left behind frequently faces lowered income and increased financial challenges. In an effort to address the dual issues of drugs and crime, we have adopted an uneasy mix of public health and public safety approaches. We treat the substance use as a health problem and punish the illegal behavior with jail. But the individuals treated and punished often return to drug use and to jail. These policies have proven to be ineffective in addressing the social problems affecting these historically underserved and underrepresented communities that lead to substance use in the first place.

Since 2009, we have seen great improvements in the numbers of New Yorkers with HIV who are linked to care and have experienced significant viral suppression. But inequalities in these areas remain among minority groups. Women were more likely to gain access to care than men but achieved lower rates of viral suppression. Viral suppression was higher among Whites than among people of color. Furthermore, the percent of people infected with drug-resistant HIV increased from 11% in 2010 to 17% in 2013. If this pattern follows others trends, people of color will be more affected by this than Whites.

New York State's Plan to End the Epidemic focuses on increasing the number of people who achieve and maintain an undetectable viral load, since that leads to a longer life and lower risk of HIV transmission. In a study of 407 people by the Medical Monitoring Project, 62% of New Yorkers reported complete adherence to their HIV meds during the preceding three months. Women, Blacks, and older adults reported the highest adherence levels. Finally, NYC partner notification services assisted in early detection of new cases and linked the newly diagnosed to care. NYC has taken bold steps towards stabilizing of the epidemic but health inequalities still remain. Hopefully, Governor Cuomo's recent announcement of $200 million in funds to end the epidemic in NYS will address this longstanding problem.

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This article was provided by AIDS Community Research Initiative of America. It is a part of the publication Achieve. Visit ACRIA's website to find out more about their activities, publications and services.

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