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In 1928, Louis Israel Dublin wrote “An improvement in Negro health, to the point where it would compare favorably with that of the white race, would at one stroke wipe out many disabilities from which the race suffers, improve its economic status and stimulate its native abilities as would no other single improvement. These are the social implications of the facts of Negro Health”. This compelling assertion remains valid to date. The fact that the African American population is the least healthy ethnic group in the USA is not due to chance. The first African Americans were brought to the USA in chains as slaves. The transport itself from Africa to the New World remains one of the best examples of the ability of one sector of humanity to destroy the health of another. Estimates of the death rate of slaves during the infamous “middle passage” are wide ranging, from approximately 9 to 35 %. Slavery associated deaths were likely much higher.

Once enslaved in what is now the USA, African Americans were forced to live in physical and social conditions in which their health had very little value. For more than 250 years, enslaved African Americans suffered physical, social, and mental brutalization. The end of slavery did not mean that African Americans could suddenly lead healthful lives. To the contrary, they have been subjected to systematic discrimination and oppression for the 150 years since slavery was abolished, and it continues nowadays. Healthwise, this history may be viewed as resulting in two outcomes. With so much suffering and early death, those who survived this subjection may be the strongest and most resilient members of this group. However, the history of slavery and the current racial discrimination this group continues to suffer clearly underlie the inexcusably poor health status of African Americans as a whole.

In 1984, Margaret Heckler, then Secretary of Health and Human Services (HHS), dissatisfied with the way health disparities were being reported to Congress, provided the first comprehensive review of health disparities endured by black and minority groups, compared with whites; the report laid the foundations for action to eliminate these disparities through health education, promotion, and access to health care. One of the most significant outcomes of the 1985 Report of the Secretary’s Task Force on Black and Minority Health, also known as the Heckler Report, was the creation of the Office of Minority Health in 1986, with the mission “to improve the health or racial and ethnic minority populations through the development of health policies and programs that will eliminate health disparities.” The Heckler Report called health disparities among minority groups an affront both to our ideals and to the ongoing genius of American medicine.

Thirty years after the Heckler Report was released, African Americans still endure unacceptable health disparities and lack the power over policy and actions that could make the changes to eliminate such disparities. In this paper, we review the scientific and “gray” literature on the health status of African Americans, using PubMed and government and non-government sources. Our literature search was focused on past reviews and reports and is not a comprehensive review of recent scientific research on African American health, but a review of topics that the published literature identifies as being the top priorities for improving the health status of blacks in the USA.

This review is guided by a modified social ecological model that includes the social determinants of health, health disparities, main health needs, and access to health services. Recommendations are offered to help frame policies and interventions to ameliorate African American health disparities. Our conceptual model allows us to relate social (distal) determinants, with individual (proximal) determinants of health. Social determinants of health include the main variables of health inequalities, namely, race, poverty, and gender. These influence health needs (morbidity, mortality, and health risks). The social response to health needs is represented by health services (policies, access, utilization, and workforce), which in turn influences health needs and risks, by hopefully resolving or improving them. Given the amplitude of our model, we delimited content to top priorities, as supported by the relevant literature. A conceptual model or framework is not intended to represent a universal truth; its purpose and usefulness is to help comprehend and transform reality. Unidirectional, static relationships depicted in a framework do not accurately reflect the historical and social world we live in—including the health of African Americans—since social determinants of health are in turn influenced by the health status of the population; also, health risks influence the social determinants of health and modulate health policies and services. Health outcomes in turn modify health risks and influence the social response by health services. The relationship between social disparities on health status of disadvantaged population has long been documented, although a direct causal pathway remains elusive. In this complex causal network, social determinants of health include cultural mores that influence and are influenced by the health status of populations. It should be noted that the term “health disparities” is used in this paper indistinctly from “health inequalities”; the former being any imbalances in health burdening a particular subgroup of the populace  and the latter understood as unjust, unnecessary, and avoidable differences affecting mostly racial/ethnic, gender, and socioeconomic vulnerable groups. While these terms can be semantically and conceptually distinguished, it is beyond the scope and space of this paper to do so. Also, the terms “black or African American” are used interchangeably to denote individuals that self-identify as such, as used by the US Census.

biomedcentral.com

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