Health Disparities: Thoughts on Distributive Justice

Driving three miles along I-94 just south of Minneapolis will take you past two neighborhoods where the life expectancy of residents differs by 13 years. Residents in Kansas City, Missouri, neighborhoods only three miles apart have a life expectancy that differs by 14 years. The situation in New Orleans is even more extreme—residents living just a few miles from each other have life expectancies that differ by 25 years. Understanding health disparities and their causes can provide valuable insight into the daily challenges faced by many of our patients and how those challenges impact how we provide their O&P care. This article examines healthcare disparities using the County Health Rankings Model, select writings of a prominent proponent of healthcare equality, and the principle of distributive justice.

The County Health Rankings Model The information about life expectancy in the previous paragraph is available on the website of The Robert Wood Johnson Foundation (RWJF), the largest philanthropic organization in the United States that focuses exclusively on health and awards grants to fund programs "to improve the health and health care of all Americans." 1,2 One such program is the County Health Rankings & Roadmaps, which provides detailed information on a variety of health and healthcare metrics for each county in the United States. You can view the results for any county by navigating to www.countyhealthrankings.org and entering the appropriate zip code into the search bar. 3 What the RWJF data shows in a compelling, graphic manner is that vast disparities in length and quality of life are an undeniable reality across our nation.

The RWJF data about US counties is organized around "a model of community health that emphasizes the many factors that influence how long and how well we live." 4 The model (available on the web in interactive form) is intended to guide the development of policies and programs by describing the extent to which four categories of health factors contribute to length and quality of life (Figure 1, pg. 28). These categories are the physical environment (10 percent), social and economic factors (40 percent), clinical care (20 percent), and health behaviors (30 percent). Within those categories, the model provides information on 13 factors ranging from housing and transit, air and water quality, and community safety, to employment, income, and diet and exercise.

As healthcare providers, our efforts are focused on clinical care, but we frequently observe how other factors impact our patients' health and the care we provide. Patients who are chronically late for appointments, struggle with obesity, have poor hygiene, or lack family support demonstrate in practical ways the close relationship between O&P care and other health factors. Sometimes these other factors represent a greater barrier to function and complicate treatment more than patients' diagnosis or physical disability.

University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2020. www.countyhealthrankings.org Social Determinants of Health It is a common perception that factors contributing to health status are within an individual's control. The fact that conditions such as heart disease and diabetes are considered lifestyle diseases demonstrates to what extent we consider them caused by a person's behavior. There is no question that specific choices and behaviors exacerbate or even cause some medical conditions, but a more nuanced evaluation reveals underlying factors that strongly influence choice. According to the County Health Rankings Model, only 30 percent of health outcomes are related to tobacco, alcohol, and drug use, sexual activity, diet, and exercise. Environmental and socioeconomic factors make an equal contribution.

An unequal distribution of the resources that support healthy behaviors can create systems of disadvantage that contribute to disparity in outcome. The social determinants of health "include the conditions in which people are born, grow, live, work and age, and the fundamental drivers of these conditions: the distribution of power; money; and resources." 5 Working backward through a series of related factors can demonstrate some of the many ways that they are interrelated: A stable, high-paying job reduces barriers to health and increases access to quality medical care. Education level is closely tied to employment and income. A stable and safe home environment are necessary for successful participation in the education opportunities. An unstable and unsafe home environment can create a series of disadvantages that limit education, employment and income, and access to quality care. In the end, these conditions result in a lower quality of life and an earlier death.

Some of the most important health factors are completely outside of the control of infants and children. All of us begin life completely dependent on others and unable to make healthy decisions, but decisions made for us in those early years impact us throughout our entire life. Not only can health conditions acquired during childhood continue into adult, but health values and habits learned during those crucial early years also influence adult behavior.

Imagine a child growing up in a disadvantaged neighborhood and suffering from a series of adverse childhood events (physical and sexual abuse, neglect, etc.). There is no grocery store near their neighborhood (but fast food restaurants abound), and the apartments they live in for four to six months at a time have inadequate heating and plumbing. These and other factors raise constant challenges to school attendance and engagement with learning. A lower level of education results in limited job opportunities and lack of health insurance. Even when healthcare services are available, the access to and quality of those clinical services are often limited. Arguing that individuals raised in these circumstances are responsible for their own poor health because of their bad choices ignores the significant impact of these and other life circumstances. 6

A patient's health is determined by more than just his or her decisions. The complex interrelationships of the social determinants of health require that we consider what is supporting or hindering each person's health choices. "Our rush to blame the poor for their irresponsibility in indulging in risky behaviors that are bad for their health should be tempered by knowing that social disadvantage in childhood might have had an enduring influence on adult behaviour." 6 The life expectancy and quality clock has started ticking long before our patients cross the threshold of our exam rooms. Understanding that the relationship between cause and effect is more complicated than the most recent decisions our patients have made can give us a more accurate perspective on how to work with them in addressing their health needs.

The Social Gradient Michael Marmot, MBBS, MPH, PhD, FRCP, FFPHM, FMedSci., chair of the World Health Organization's Commission on Social Determinants of Health, describes the strong evidence "demonstrating the presence of a social gradient in health outcomes associated with the unfair distribution of the social determinants of health." 5 These differences can be seen within highly resourced countries, and not just when comparing rich and poor countries. For instance, in Baltimore, there is a 20-year difference in life expectancy between those on the highest and lowest ends of this gradient. This is equal to the gap in life expectancy "between women in India and in the USA." 6 Additionally, Marmot points out that "the social gradient in health includes all of us so-called average people." 6 Members of a population live at different places on the spectrum of advantage and disadvantage, "not on a different spectrum. The scientific challenge, then, is to understand why inequalities in health run from top to bottom of the social hierarchy…." 7 In a view that is sure to have detractors, Marmot believes that "policies need to consider both the people at the bottom of the health gradient and the gradient as a whole, ensuring that their impact is proportionately greater at the bottom end of the gradient." 5

Recognizing the impact of social determinants at every socioeconomic level can help us recognize how important it is for everyone that they be addressed. The gradient "engages all of us. Ill health of the poor can excite prejudice: The poor are the architects of their own misfortune; worrying about them only encourages fecklessness. If of a different political persuasion, we might think that it is wrong that we organize affairs such that the poor suffer ill health, but at least we are not so affected. The gradient gives the lie to both of these. In England, people in the ‘middle' of the social hierarchy will, on average, have seven fewer years of healthy life than if they were at the top." 7 By addressing the problems at the root of the gradient of healthcare disparities we may be able to improve healthcare for everyone.

Distributive Justice According to Marmot, "If health of a population suffers it is an indicator that the set of social arrangements needs to change…. If the major determinants of health are social, so must be the remedies." 8

Healthcare disparities are ultimately an ethical issue. In their classic text, Principles of Biomedical Ethics , Beauchamp and Childress describe justice as one of the four principles of biomedical ethics. At a basic level, justice refers to fairness—everyone getting what is due to them. Some ways of applying this principle are the distribution of healthcare to each person according to his or her need, effort, contribution, merit, or free-market exchanges. 9 Like all ethical principles, this one raises its own set of dilemmas. A system in which everyone receives as much or as little healthcare as he or she can afford could be considered fair, but the vast disparities in the length and quality of life seen in such systems can hardly be considered just in any meaningful sense. Discussions on this subject are inherently political, and people often line up behind common partisan interpretations of justice and proposed solutions. Despite these difficulties, discussions about this important issue can help us make practical decisions about how resources are distributed within our spheres of influence.

Practical Implications Most of the interventions we provide contribute much more to the quality of life than overall life expectancy . However, supporting mobility and higher levels of independence when completing activities of daily living may have more significant long-term effects than we think. We can take practical steps toward learning more about our patients' challenges by initiating frank discussions about how the social determinants of health impact them. Chronic tardiness may be a result of an unsupportive domestic arrangement and limited transportation options. Inadequate care and cleaning of a device may be closely related to substandard housing. Management of diabetes may be complicated by limited nutrition options.

The improved understanding engendered by these discussions can translate into more sensitivity and grace, and a commitment to offer support when we can. Our assessments usually focus on less personal information, and it will take some time and practice to learn how to ask these questions in a constructive manner.

Closing Thoughts A short drive through the communities where we live and work will take us through neighborhoods where people experience vastly different levels of advantage and opportunity.

To put it more starkly, many of us live only a short distance from people who lack many of the resources required for a long and healthy life. We see these individuals as patients in our practices and observe firsthand the devastating cumulative impact that disadvantage has on their health. Much of the pain and suffering they experience is unrelated to choices they've made, and even those health conditions that are caused or complicated by their choices occur within a particular context of disadvantage from which many of us have been sheltered. Likewise, the privileges that many of us enjoy go well beyond what we have earned by our own behavior and choices. Considering this state of affairs should at least cause us concern, and on a human level these disparities often break our hearts.

There are no simple solutions to the problems of inequality and its consequences in the lives of our patients. There is not likely to be one policy, program, or party that will resolve inequity in a completely just manner. We, however, can begin to mitigate the negative effects of inequality by having a deeper and more nuanced understanding of the complex interactions between factors within and outside of the control of our patients and supporting their best efforts.

J ohn T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 25 years of experience in patient care and education. He can be contacted at john.brinkmann@northwestern.edu. References 1. "Mapping Life Expectancy," Robert Wood Johnson Foundation, accessed May 1, https://www.rwjf.org/en/library/articles-and-news/2015/09/city-maps.html. 2. Robert Wood Johnson Foundation, Wikipedia, accessed May 1, https://en.wikipedia.org/wiki/Robert_Wood_Johnson_Foundation; https://www.rwjf.org/. 3. "County Health Rankings & Roadmaps," 2020 County Health Rankings State Reports, accessed May 1, https://www.countyhealthrankings.org/. 4. "County Health Rankings & Roadmaps," County Health Rankings Model, accessed May 1, https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model. 5. Marmot, M, R. Bell. 2012. Fair society, healthy lives. Public Health 126:S4-10. 6. Marmot, M. 2015. The health gap: the challenge of an unequal world. The Lancet 386(10011):2442-4. 7. Marmot, M. 2017. The health gap: the challenge of an unequal world: the argument. International Journal of Epidemiology 46(4):1312-8. 8. Marmot, M. 2005. Social determinants of health inequalities. The Lancet 365(9464):1099-104. 9. McCormick, T. R. "Principles of Bioethics," School of Medicine, University of Washington, accessed May 1, https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics.

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