Early in 2008 I received an invitation to attend a regional meeting of Northwest states regarding the issue of health disparities. Where was this meeting held? In Scottsdale, Arizona, of course! Go figure. Anyway, in the spring of 2008 I hopped aboard a plane and left the chillier northern climate of my hometown, Anchorage, Alaska, and headed off to the warmer delights of Scottsdale, Arizona. This meeting was sponsored by the National Partnership for Action, a program out of the US Department of Health and Human Services' Office of Minority Health (OMH). The mission of the National Partnership for Action is to "mobilize and connect individuals and organizations across the country to create a nation free of health disparities with quality health outcomes for all people." The guiding theme of this regional conference was that "the existence of health disparities among minority populations is undisputed, and the question that confronts us is what actions can be taken by private and public partners that would improve the effectiveness and efficiency of our collective efforts?"

The attendees at this conference were a rainbow of skin colors, ethnic groups, religions and lifestyles from all over the Northwest. For the most part these were people who were on the ground as healthcare providers or as activists struggling to turn health disparities into health equity. These were not stuffy people. During the evenings, after the last speaker had spoken, and after the last note was taken, we went out for beer and pizza. We had long discussions about our work in our communities and about the broader issues. We had some fun along the way, and many of us became good friends.

Some of the conference involved plenary sessions which were attended by the 250 or so people who were at the conference. In these plenary sessions we discussed some of the details of health disparities among minorities. A standard definition of a health disparity is,

"A particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment based on their racial or ethnic group, religion, socioeconomic status, gender, mental health, cognitive, sensory or physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion."

That definition is a little weighty, but you get the idea. The opposite concept is "health equity." The definition is much more concise: "Health equity is attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities."

Some examples of health disparities among minorities include:

* Among African American infants, the mortality rate is 2.3 times higher than for white infants
* Among African Americans, the rate for hospital admissions for diabetes related lower extremity amputations is 2.3 times higher than for whites.
* Among American Indians and Alaska Natives, the rate for diabetes mellitus was nearly twice as high than for whites; and compared to white women, American Indians and Alaska Natives were more than twice as likely to not receive prenatal care in the first trimester.
* Asians, Native Hawaiians, and other Pacific islanders are 1.6 times more likely to contract hepatitis A as compared to whites.
* Hispanics/Latinos are 3-1/2 times more likely to contract HIV/AIDS, and twice as likely to die from it compared to non-Hispanic whites.

Health disparities are clearly life and death issues. What causes them? The general understanding among conference participants and to some extent in the conference literature was that many of these factors predate the appearance of a disease state. These are social and environmental factors rather than medical issues, and are fundamentally and particularly toxic to health. Well known factors include low socioeconomic status, low educational status, and inadequate access and utilization of quality health care.

There are other adverse determinants of health as well. Examples include residence in geographic areas that have poor environmental conditions (e.g., violence, poor air quality, and inadequate access to healthy foods), racism, inadequate personal support systems, and limited literacy or limited English proficiency. These determinants are often associated with racial minority, ethnic minority, and underserved communities.

Some of us tried to go a step further and discuss the relationship of health disparities to a for-profit medical care system, combined with a for-profit health insurance system in the environment of capitalism. These two profit maximizing systems combine to produce and maintain health disparities among low-income and increasingly even among middle class families. Hospitals and most health care providers are primarily interested in maximizing revenue, and it does not matter to them if tens of millions of Americans are priced out of the "market." Health insurance companies routinely deny legitimate health care to their clients in order to maximize revenue, and racism sharpens this effect among lower income and minorities.

The conference lasted several days and it was very intense. Much of the conference involved smaller working groups of about 20 or 25 people. The participants in these working groups often formed close friendships during the course of the intense discussions that took place in the groups as well as in the bars and restaurants later in the evenings. It became clear that many of the participants at this conference were activists, community organizers, and health care providers in low income neighborhoods who did not need lengthy definitions of health disparities to understand the reality of them in their communities and to understand the variety of social causes in their communities.

Remember that this conference took place during the time of the Bush administration before the election of Obama. On paper the goals of this federal program looked pretty good, pretty progressive, and many of the attendees were very progressive organizers and activists in their hometowns. As a result, as a whole, the participants of this conference were not about to be led down a political garden path. As I noted earlier, most of the time in this conference was spent in smaller working groups.

According to the agenda, the goal of these working groups was to determine what the highest priority health disparities in our various communities were, and what could be done to address them. The conference facilitators had in mind bland and politically innocuous goals they repeatedly and forcefully attempted to influence and guide us to recommend, such as the creation of state offices of minority health, or various educational programs to promote awareness.

But as I said earlier, most of the participants in this conference had a long history of being engaged in struggle around these issues. They were way past proposed solutions such as bureaucratic and politically emasculated offices in some state bureaucracy, or ineffectual attempts at creating "awareness" of the issues in their respective communities. No, that was not going to work no matter how hard the facilitators pushed, cajoled, and manipulated attendees in the workshops to try to come up with these kinds of programmatic goals.

In the workshop that I was in by the third day the facilitator had become clearly quite exasperated with his charges. We on the other hand had become quite unified around one primary high-priority solution to the issue, and it was not at all what the facilitator wanted to hear, nor what a program goal in the Bush administration was supposed to be. We as a group finally and unalterably decided that the single most important thing that had to be done to address health disparities in America was universal access to high quality health care for all residents in the United States.

Participants were divided about whether this could be single-payer, or this could be a national health service. Perhaps it could take other forms, but it had to offer universal, unimpeded access to high-quality health care for all residents of the United States. We collectively understood that this single structural change would be the most effective way of addressing health disparities in the United States.

By the end of the third day that had become our highest priority goal. The facilitator, exasperated though he was, became resigned to formally placing our working group's proposed solution in the formal meeting notes. The last day of the conference all the working groups met in a plenary session. There were about eight or ten working groups that met and had gone through the same process we did. During that plenary session a representative from each working group got up and talked about their group's view of what the highest priority health disparities were and what could be done to address them. Despite the unanimity of purpose of the official group facilitators, nearly every group independently reached the same decision, that universal access to high-quality health care was either the highest priority to address the question of health disparities in the United States or was among the highest.

There is a moral to this story. The moral is if you are going to bring together 200 or 300 community organizers, labor activists, progressive healthcare providers, and progressive political street fighters, they are going to set their own agenda and they are going to achieve it. They understand health disparities. They understand health equity. Most importantly, they understand how to get from the former to the latter.

It is not too late to contact the White House and members of Congress and demand a strong public option, a strengthened Medicaid and Medicare, and a very significant increase in public support for the thousands of Community Health Centers across the nation, and vastly strengthened consumer protection regulations over the health insurance industry.

The underlying theme: people before profits! The health of the people comes first!

Photo by U.S. Navy.