Life Course, Social Determinants, and Health Inequities: Toward a National Plan for Achieving Health Equity for African American Infants—a Concept Paper

Abstract

Despite the best efforts by the public health community, the existence of disparity in African American infant mortality appears to be insurmountable. Eliminating this disparity is the public health challenge of the next decade. The public health community has engaged in copious activity regarding the identification and analysis of the etiology of health disparities. The resulting literature is substantial, yet, despite well-meaning interventions that have had varying degrees of success, the problem is so daunting that there has been very little progress in developing a comprehensive national plan to eradicate health disparities, in general, and, African American infant-mortality disparities, in particular. The process of identifying the causal pathways and risks of adverse African American birth outcomes could potentially impact the elimination of other health disparities since infant outcomes are the foundation for adult health. Unfortunately, as a nation, we have never deliberately invested the time and resources into developing an evidence base specific to the achievement of health equity. This endeavor will require dedicated resources, creativity, and a breadth of vision to work within, and exceed, the limits of traditional epidemiological and social science theory and methods. The literature cites various causes of overall disparities, including adverse health behaviors like smoking or drug use, poor nutrition, inadequate health care, and stress, to name a few [1]. The World Health Organization (WHO) Commission on Social Determinants of Health considers the major contributors to health disparities to be the conditions in which people are born, grow, live, work, and age [2]. In the United States, ethnic minorities, particularly African Americans, are more likely to be in socially and economically vulnerable positions. A number of studies have demonstrated that even while controlling for SES, racial and ethnic disparities are still found in health outcomes [3]. For example, African American women in Illinois at the highest education level have higher, i.e., worse low-birthweight rates than women of any other ethnicity at lower strata. The process that determines social stratification leading to poorer health outcomes is rooted in history, and while it is not about ‘‘race’’ as a risk factor, scientific investigation has resulted in a corpus of knowledge that places racism, perceived acts of racism, poverty, socialenvironment degradation, and violence into the etiological pathway [4–10]. These manifestations of ‘‘social ecology’’ are the type that WHO describes as resulting in unfair and avoidable differences in health status [2]. Some think that because racism is a causal factor, any quest for solutions may be doomed to failure, because, as one funding institution’s peer reviewer stated, ‘‘It is not a good investment of [our] dollars to study racism [as a cause of health disparities], because even if we fund something, there is nothing we can do about it’’ [11]. However, pre-term birth (PTB) and low birth weight (LBW) are the causes of firstyear mortality for African American infants. Therefore, understanding and eliminating the factors that cause high rates of PTB and LBW should remain at the forefront. V. K. Hogan (&) ! D. Rowley ! T. Bennett Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 425 Rosenau Hall, 421 Pittsboro Street, 135 Dauer Drive, Campus Box 7445, Chapel Hill, NC 27599, USA e-mail: vhogan@email.unc.edu