Finding Upstream Solutions to Health Inequalities

As part of an overview plenary, Debra Furr-Holden, of Johns Hopkins University, delivered a powerful address on the need to identify upstream causes of health inequality in the United States. In discussing the meaning of “health disparities,” Furr-Holden emphasized the distinction between the terms “disparity” (or “difference”) and “inequality,” noting that discussions of disparity place the focus on differing health outcomes downstream, rather than their causes. “Wherever we look at the problem,” she said, “that typically tends to be the same place where we look for the solution.”

Furr-Holden also provided examples of projects she has been involved in through the Johns Hopkins University Urban Health Institute, and how they had been transformed by shifting the focus to upstream solutions. In one example, a program originally designed to provide legal services to young black men became a citizen’s advisory council that worked with community police to identify why a disproportionate number of young black men were arrested (and therefore required legal services) to begin with. “The problem isn’t that these young men need legal representation, which they do,” Furr-Holden explained. “The problem is that we have racism in the enforcement strategy of our laws. If we can create programs, let’s create programs to deal with those things.”

In a later panel, Wayne Duffus, of the US Centers for Disease Control and Prevention, echoed Furr-Holden’s sentiments by emphasizing that not all differences are unfair or unjust, but that health inequality stems from the systematic and unjust distribution of resources.

Duffus explained that, in the United States, discussions of health disparities often focus on race, but that race is not a modifiable driver. Governments have some ability to address other drivers that play a role in health disparities, like income, education and incarceration. Referring to a diagram of the Health Impact Pyramid, Duffus emphasized the need to intervene at all levels to change health outcomes.