OBSERVATIONS - August 8, 2008
The Changing Face of America
Who you are, where you live, and what resources are available to you impacts your health. These basic ideas drive a great deal of public health research and advocacy, which aim to identify what interventions improve health the most. To be successful, these efforts must take into account how “who we are” as a country is rapidly changing, but must also recognize the continued impact of social, economic, and environmental factors on the health of all population groups.
California is a microcosm of the country’s population changes. In 1980, the U.S. Census found that about two-thirds of California’s population was non-Hispanic White. By 2000, California was a “minority majority” state – over one-third Hispanic, 13% Asian or Pacific Islander, and 7% Black – and these trends continue today. California’s rapid demographic shifts are a preview of sorts, as the diversity of the U.S. population is projected to continue to increase in coming decades. This cultural heterogeneity contributes to revitalization of communities and broadens and enriches the experiences of our population as a whole.
At the same time, not all segments of this diverse population have similar access to and opportunities for good health. Disparities in health status and health care processes for different racial and ethnic groups have been well documented, but less attention has been focused on how the changing composition of our population affects (or should affect) approaches to reducing these disparities.
That nexus – where demographics and health disparities intersect – was the focus of a recent public workshop of the Institute of Medicine (IOM) Roundtable on Health Disparities, “America in Transition, A View from California: Implications for Addressing Health Disparities.” To provide context, early presenters at the workshop focused on how data illuminate disparities and their influences (creating an impetus for action); how institutional and social practices and norms – such as economic development, disinvestment trends, and migration patterns – contribute to inequities; and how “framing” the issue of health disparities can engage various stakeholders (or not).
Discussion about the experiences of three California communities whose populations have transformed in recent years – East Palo Alto, Fresno, and South Central Los Angeles – brought these issues to life. Leaders from local community clinics, city councils, health departments, health improvement initiatives, and community organizing and economic development entities discussed how the major demographic transitions in their communities are impacting strategies to address health disparities. Though the experiences and most urgent problems of the communities differ, several common themes emerged from their stories:
- While the composition of these communities has changed in recent years, many of the problems have generally stayed the same: poverty, violence, lack of investment, and insufficient opportunities.
- Violence impacts health of communities at multiple levels, and must be treated as a health problem, not just a criminal justice problem. As one speaker said, “You can’t fix the health problems without fixing the social and economic conditions.”
- Some communities have an abundance of resources, but insufficient access to or control of these resources. A stirring example is the case of California’s Central Valley, an agricultural giant that feeds the country, but where many farmworkers have insufficient access to healthy foods and obesity and diabetes among these low-wage workers run rampant. As one speaker said, community members are incurring “all of the cost and none of the benefit” of the local industry.
- One of the strongest community assets is the desire and motivation for self-determination, such as East Palo Alto’s incorporation as their own city to avoid further loss of control, and all three communities’ experiences forming collaborations to address local problems.
- The culture of low expectations and limited opportunities in communities has a tremendous influence on the choices and paths of residents, and perpetuates inequalities.
- Infrastructure matters. Investment in public goods such as lighting, sidewalks, parks, and crime prevention is needed along with more typical health care services.
- Discrimination is the “elephant in the room” with respect to these communities’ challenges and health disparities, and requires continued dialogue.
While the workshop raised more questions than it answered, it put a face on the issue of health disparities by focusing on the connection between community environment (physical, cultural, and political) and health. The demographic changes in these communities will alter some of the approaches taken to improving health outcomes – through culturally or linguistically appropriate interventions – but the core problems of poverty, violence, and lack of investment and opportunity remain the same and require renewed focus if health disparities are ever to improve.
- Kate Meyers, MPP, Senior Policy Consultant,
KP IHP
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