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