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December 29, 2008

Q&A: The Truth about Health Disparities

Health disparities are differences in health status by race, ethnicity, gender, social class or urban and rural population. African American, Hispanics, Native American and Asian/Pacific Islanders in particular are at an increased risk for developing diabetes, cancer, heart disease and stroke and are more likely to have higher rates of substance abuse, infant mortality and low birth weight than their non-Hispanic white peers. For many years these disparities have been primarily associated with genetic differences among races, however, current research shows that external factors such as environment and behavior could play a substantial role.

To learn more about health disparities, the Office of Communications and Public Affairs spoke to Thomas LaVeist, PhD, director of the Johns Hopkins Bloomberg School of Public Health’s Hopkins Center for Health Disparities (HCHDS) and the William C. and Nancy F. Richardson Professor in Health Policy. LaVeist has authored several publications on health disparities, including "Minority Populations and Health: An introduction to health disparities in the U.S." He recently created the Cultural Competency Organizational Assessment –360 (COA360), a tool for assessing the cultural competency of health care organizations.

Question:  Why is it important to study and address health disparities?

LaVeist: In the U.S. it’s extremely important to address these disparities because the populations that we currently call minorities are growing rapidly. Current estimates indicate that around the middle of the twenty-first century minorities are expected to comprise the majority of the population. This could cause the cost of care to increase substantially and the health profile of the nation to decline. In addition, the U.S. has an aging white population leaving the two demographic groups—minorities and elderly whites—in need of increased care. This would be extremely problematic since a younger, sicker working population could also have serious implications for the economy, ultimately leading to less productivity and potentially affecting the country’s standing internationally.

Question: If health disparities increase, how will this affect the availability and quality of health care?

LaVeist: We will have to allocate more societal resources to health care since more people will utilize those services.  The U.S. already devotes a tremendous amount of resources disproportionate to any other industrialized country to health care. As our population continues to age, the government-sponsored Medicare program, which is for the elderly, will see demand increase. America will to have to manage the care of a larger percentage of people and the aging population. In addition, the Medicaid program for low income families currently serves a disproportionate number of minorities. To sustain both of these programs the government will be forced to change eligibility requirements so that fewer people are eligible or they’re going to have to increase the amount of resources allocated to the programs to keep up with increased demand.

Question: What is the Hopkins Center for Health Disparities Solutions doing to address these problems and issues?

LaVeist: Well, we do several things; one of our objectives is to conduct research with the goal of pinpointing possible places to intervene with policy or programs. We have found that health policies often lack a clear understanding of what causes health disparities, so we conduct research to try to increase the likelihood that policy interventions will be successful and appropriately targeted. Using tools such as COA360 (COA360.ORG), we examine various health systems, health care organizations and try to help find ways to provide resources that will help them to be able to do a better job addressing the health care needs of the population served. We work closely with Congress, the Congressional Black Caucus and the Congressional Hispanic Caucus to help them think through policies addressing the disparity. In addition to race and ethnicity, we also look at geographic disparities, urban versus rural populations and even within those categories we look at proximity to hazardous waste sites or other geographic characteristics that could impact the population’s health. So it’s race, ethnicity, geography, economic status and gender.

Question:  What is COA360?

LaVeist:  Cultural Competency Organizational Assessment—360 or the COA360—is an instrument designed to appraise a health care organization's cultural competence. The Office of Minority Health in the U.S. Department of Health and Human Services and the Joint Commission have each developed standards for measuring the cultural competency of health care organizations. COA360 is designed to assess adherence to both of these sets of standards and it is a valuable tool, not only for assessing a health care organization's cultural readiness but also for benchmarking its progress in addressing cultural and diversity issues. Improving the cultural competency of a health care organization increases the likelihood that the staff can relate to the diverse patient population, lessens miscommunication between patients and providers, and heightens provider and staff sensitivity to the values, beliefs and health-related practices of patients. This leads to greater acceptance among patients of the organization's health education message, improved accuracy of diagnoses and interventions and better patient adherence to prescribed treatment regimens. The ultimate results are higher patient satisfaction scores, more positive health outcomes, and the narrowing of health disparities

Question: How do we begin to close the gap on health disparities?

LaVeist:  Using tools like COA360 is a start, but we also need to close the gaps in social and economic status, access to health care and the quality of care received. All of these factors contribute to the problem. I often hear biological-or genetics-based solutions, but I believe these are copouts. If disparities are about genetics, then it is determined by factors that we currently cannot modify so there is nothing we can do about disparities. I think it is vital that we resist this line of reasoning. The evidence of significant genetic differences between race groups is extremely limited. When you hear a news report of some new study that finds a genetic basis for race disparities you will nearly always find that the gene (or mutation) is found in all populations, but perhaps in higher frequency in one group. Sometimes that gets interpreted as a genetic difference between race groups rather than interpreting it more accurately as a greater frequency of the gene in one group and an association between the gene and the health outcome. So the emphasis is placed on race rather than the gene. Moreover, the leading contributors to race disparities in health have complex etiology. They are not single-gene diseases (heart disease, cancer, stroke, etc.).  On the other hand, socioeconomic status and other psychosocial factors tends to be associated with nearly every major cause of death. This is not to suggest that there is no role for genetics in health disparities. There certainly are gene and environment interactions that can lead to race differences in mutations or gene frequencies. My suspicion is that this is the reason for most differences in the distributions of gene frequencies that have been observed.

Question:  Is there anything else you would like to add?

LaVeist:  Racial and ethnic disparities are a mounting problem that will increasingly affect the nation on many fronts. It is a ticking bomb that will have policy, economic and political implications. At the HCHDS we also have a study to look at the economic burden of health disparities where we seek to demonstrate the impact of disparities on the economy. This project could be influential in making the case that we need to continue to devote resources to this important problem.—Natalie Wood-Wright

Media contact for Johns Hopkins Bloomberg School of Public Health: Natalie Wood-Wright at 410-614-6029 or