Tracey Koehlmoos: Martin Luther King day and health inequalities in the US

Tracey KoehlmoosMartin Luther King day provides an opportunity to reflect on the civil rights movement as well as the broader issue of inequalities that face every nation. Because King’s “I have a dream” speech is so ubiquitously placed in two generations of middle and high school education, it is hard for many people my age or younger to remember that during his life he was a controversial figure. King espoused the Gandi’s non-violent approach and started what can be considered the original “occupy” movement.

In the US, many people have stopped talking about civil rights and move through their lives with the sincere belief that equality has been achieved. The Civil Rights Act of 1965 assures us that we will not be discriminated against based on race, colour, religion, or nationality. Many people celebrate Martin Luther King’s day in the US by sleeping late or hitting the sales at the mall rather than considering the origin of the date or the need to create a more just society. In some areas like education achievement and health status, disparities continue to exist.

In 2003 the Institute of Medicine (IOM) published a comprehensive study which demonstrated that “racial and ethnic minorities received a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled” (1). The essential message of this report was that the health of the individual cannot be separated from the health of the larger community and from the health of the state and the nation. The term disparities can be defined in a number of ways. The IOM study defined disparities as racial or ethnic differences in healthcare that were not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.

The federal Healthy People 2010 initiative established the goal of eliminating racial and ethnic disparities in six major areas, including cancer (2). However, that deadline passed without fully achieving equity in healthcare. The good news is that in the US life expectancy at birth increased slowly and steadily across all races in the US from 2000 to 2009 with African American men and women closing the gap. 

The US is not alone in its struggle to address inequities among subgroups of the population, so that even labelling the idea uses different words within the same language. In the US, the word disparities is generally used to describe the differences between groups and in the UK the word used is “variation.” In global health we use the phrase, “equity.”

If you do not work in global health and hear the word “equity,” you might think of it in terms of building financial capital. However, in global health terms, equity is about more than differences or variations based on gender, skin colour, or religion and there are two documents that are frequently employed to capture differences across groups.  The most frequently used tool was developed by Timothy Evans and Hilary Brown (3) and is  an acronym called PROGRESS which stands for place of residence, race, occupation, gender, religion, education, socio-economic status, and social capital. Later systematic reviewers from the EPPI Centre led by Josephine Kavanaugh (4) suggested that PROGRESS should be expanded to incorporate other important factors that can impact health equity such as disability, sexual orientation, and age. This second tool is called PROGRESS-plus.

Because Martin Luther King made so many inspirational statements that ring true today in the US and in the far corners of the planet like Bangladesh, I will leave you to ponder civil rights, social justice, and global health equity with three of my favorite quotations:

1) The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.
— Martin Luther King.

2) We must learn to live together as brothers or perish together as fools.
–Martin Luther King.

3) All labour that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence  –Martin Luther King.

(1) Institute of Medicine. (2003). Unequal treatment: confronting racial and ethnic disparities in healthcare. (B. Smedley, A. Stith & A. Nelson, Eds.), Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press.

(2) U.S. Department of Health and Human Services. (2000a). Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office.

(3) Evans T, Brown H. 2003. Road traffic crashes: operationalizing equity in the context of health sector reform. Injury Control and Safety Promotion 10: 11–12.

(4) Kavanagh, Josephine and Oliver, Sandy and Lorenc, Theo (2008) Reflections on developing and using PROGRESS-Plus. Equity Update, 2 (1). pp. 1-3

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.