Thursday, October 22, 2009

Response to Ideas about Racial HIV Disparities

I've heard varied responses to the article, "Racial HIV Disparities Are an Indictment of the US Response to the Epidemic." Here are my thoughts...

I didn’t interpret this article as saying it is entirely the responsibility of government to address the HIV epidemic in the African American population. However, the authors point out that the current strategies, which focus primarily on behavior change, are not sufficient. They cite evidence that when infection rates are controlled for by a broad range of demographic and behavioral variables, the inequity still exists. In particular, they note that “exposure to the virus is more likely among blacks than among whites for any given number of partners or frequency of sexual contacts.” They cite social and economic factors that explain this.

To respond to this evidence, the authors draw attention to the importance of social determinants of health and the policies that help determine their distribution as critical factors that have not been sufficiently considered in response to the HIV epidemic. Certainly the housing policies over the last 40 years, and some, although not all welfare policies have probably contributed to the problem. Some evidence suggests that many policies from the 1960s helped reduce health inequities. Nonetheless, you make a good point: while public policy is an important part of promoting health equity, even well intended policies must be evaluated to determine their impact on health and well-being.

However, to stop at policies in the last 40 years, ignores the longer history that has disadvantaged African American communities and contributed to the current situation. Long before the 1960s, segregation existed in Virginia and in Richmond. From my understanding, laws first appeared in Richmond in the early 1900s to create de jure segregation. De facto segregation existed before then. In addition, New Deal policies, the GI bill, redlining practices of banks, steering of minorities into minority communities by real estate agents, etc. were/are all implemented in ways to encourage and reinforce segregation. Given the broader social context, it’s not surprising that higher poverty rates, lower rates of educational attainment, higher infant mortality rates, shorter life expectancy among African Americans, etc. have existed since national statistics have been collected in the U.S, and that there is a current inequity in HIV.

I agree that re-evaluating public housing policies and welfare policies is an important step to promoting health equity. Improving those policies alone will not eliminate the inequities in living conditions and experiences because segregation and the associated social context exist outside of public housing communities. Research clearly shows that low income communities and minority communities regardless of economic status are less likely to have the resources that promote health (full service grocery stores, safe and affordable places to exercise, safety, convenient transportation, job opportunities, high performing schools, positive early childhood experiences and stable families, access to quality health care, etc.).

The article points to these types of factors as being important in addressing the inequity in HIV. We also know that these factors are associated with the broad range of inequities we see among racial and ethnic minorities and low income populations around the state. Creating environments with as many positive social determinants of health as possible is just as much a health intervention as testing high risk populations, distributing condoms, encouraging safe sexual practices, etc. It’s not an either/or issue. Multi-sector partners are necessary to address all of these issues, and MAPP is a great vehicle to bring them together.

Michael O. Royster


  1. Great post-- how do you suggest that we work on balancing helping folks who are suffering now (i.e. because of sub-standard housing, HIV infection, etc) with the longer term goal of ending racism? It can be really emotionally draining to do both activities, but it also feels strange to say "we can't help you find better housing because we have to end racism first."

    How do you prioritize? Is it even possible to do both? Or should one group work on racism and another on meeting immediate needs with the occasional meeting or summit to come together and share their experiences?

  2. Michael, your post and Ashley B.'s comments are right in line with a dialogue we've been having in our communities. How do we advance tangible change (eg, policy) while not giving up the essential, enduring inquiry that is necessary to uncover the root causes of disconnect that continually manifest in the problems we face?

    Consider the Civil Rights movement, which resulted in significant structural/policy changes. And yet (in our assessment) we still do not have a meaningful, enduring national conversation on racism. Or, how about a conversation on the root causes underlying racism? Because it might be that the disconnect is more fundamental than this; that racism is but one manifestation of a way of thinking that flows from seeing the world in terms of "self" and "other"; a way of thinking that is defined by separation and control.

    What we are learning in our Communities of Health work is that nothing changes until people have the opportunity to discover for themselves what matters to health, and what we can do about it together. In short, we must un-learn and re-learn "health" as a direct, ongoing and collective experience of it.

    This is happening in a growing number of cities around the country where people are coming together to uncover the broad set of factors driving health and illness in their communities. What they discover together forms the basis of collaborative action among an expanding group of stakeholders – citizens, business, government, education, health and other sectors – who realize the collective strengths, needs, and possibilities inherent in their community.

    While every Communities of Health effort is unique, each is demonstrating that greater collective awareness and change from within can create a profound and sustainable shift in health for all. In addition to generating tangible action, engaged local participation creates "control of destiny," which is essential to health. Coming together to consider the health of the community is healthy community.

    Rick Brush

  3. Great comments by both of you. You both hit on key points: you can't do it all, so where do you start? and communities are critical in identifying, defining, and addressing the problems.

    My thought would be that whereever you start, it's always important to keep the big picture in mind and tie your specific work to the bigger root causes of what you're addressing.

    I think the health equity movement is a good example. While a diabetes program may focus on changing behaviors in disadvantaged communities, it has to look at some of the structural issues that prevent healthy behaviors in order to be successful. That requires partnering with others who can focus on creating healthy food options or making neighborhoods safer. From the community's perspective, a lack of job skills and access to employment may be another critical factor. Again, more partners are needed from different sectors. All the while, you relate each of these issues to the bigger issues. Eventually you get to the root and partner with organizations that are focused on social justice.

    I stated that very simplistically, but as you both know, it's much more complex. This is long term work we're talking about.



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