Well-meaning public health practitioners and scholars must acknowledge the reality that, too often, bias creeps into their studies and models. It is understandable that this happens; the dominant paradigm, by virtue of its ubiquitousness, is often invisible. As researchers and academics, we have come far in ridding ourselves of this bias, but it still exists, and so we must continue to overcome it. How healthy we are has everything to do with our gender, race and ethnicity, income, education, employment status, disability, sexual orientation, and where we live. Yet we still envision a “generic person” who dominates our research, who too often has little or nothing to do with flesh-and-blood reality. Here are some examples:
• Car manufacturers designed airbags for their idea of the “generic person”: a 5’9″, 170-pound, un-seat-belted man. The result is that smaller people, especially women and children, have been killed or seriously injured by the excessive force of deployed airbags. And rather than redesign airbags, manufacturers tell us to deactivate them.
• Men are more likely than women to get emergency intervention during heart attacks because women present symptoms differently from men, and mens symptoms—the symptoms of the “generic person”— are considered the norm. Our emergency professionals should be equally trained in the classic heart attack symptoms of men and women. The “generic person” construct has left women at higher risk of premature death.
• African-American women are disproportionately victims of diabetic blindness, lower limb amputations, and other complications of diet-accelerated diabetes. One must wonder what the response would be if these burdens applied to the white male “generic person.”
When researchers stop ascribing unrepresentative demographic characteristics to their study samples, their
research will begin to be targeted to those in our society who suffer the most from poor health.
In addition to weeding bias out of their models, researchers must do more comparative studies to help us isolate what holds for public health in the world, and what holds only—or disproportionately—in the US. Poor health is associated with lower socioeconomic status, but is it an inevitable outcome? The answer appears to be no. For example, there is a consensus in the US that a rise in single parent families implies a rise in childhood poverty. Yet, according to UNICEF, Sweden, the OECD country with the highest rate of single parenthood (20%), also has the lowest rate of childhood poverty (2.6%). There is a consensus in the US that high unemployment rates correlate with high child poverty rates, yet, according to UNICEF, Spain and Japan both have child poverty rates of 12%, while Spain’s unemployment rate is 15% and Japan’s is less than 5%. The same report noted that although Paris has as high a rate of poverty as Manhattan, Manhattan’s infant mortality rate is nearly twice as high as Paris.
Manhattan’s poor children are less healthy than their counterparts in Paris, largely because the French have a health system that makes it easy and affordable for parents to obtain health care and other services for their children. Comparative findings from other countries upend our assumptions and reveal that, in nations where programs exist to ensure the basic social and economic rights of all citizens—in other words, where social exclusion is not tolerated—the damaging effects of poverty can be minimized. Kawachi and Kennedy at the Harvard School of Public Health have argued that it is the gap in income, the differences in relative wealth and social inclusion in America, rather than absolute poverty, that contributes to disparities in health status.
Research needs to tell us, in greater depth and detail, what other industrialized nations are doing that is yielding better health outcomes than we enjoy. What can research teach us about remedies for the systemic causes of ill health for the poor in this country?
Poverty. Politically, we must resurrect eliminating poverty as a national priority. In 1967 and 1968, Senator Robert F. Kennedy toured several forgotten, poverty-stricken regions of the US to bring attention to the plight of the US poor. What he showed us was considered a national disgrace, and in his time, he helped to mobilize significant changes.
It is well past time to revisit this issue, to face it with the same degrees of shame at its existence and commitment to change. Because in our nation there are direct correlations between poverty and health status, poverty and educational attainment, poverty and housing, public health professionals must speak out clearly and consistently until the press and public begin to take notice. From grassroots on up to national levels, public health professionals must lead the antipoverty cause, educate local and national lead ers about the social problems brought on by poor health derived from poverty, and then offer their knowledge, expertise, and clout to help enact political solutions.
One way to start informed discussion about poverty is to abandon the federal poverty line, which is widely acknowledged as not measuring the right factors, in favor of a more realistic standard. The Self-Sufficiency Standard used by the organization Wider Opportunities for Women, for example, measures how much income is needed for a family of a given composition in a given place to adequately meet its needs without public or private assistance. The standard assumes that all adults in the family are working, includes costs associated with employment (such as child care), takes into account the size of the family and the ages of the children, incorporates regional and local cost variations, and factors in the net effect of taxes and tax credits. In short, it looks at what a self-sufficient family would need to live adequately (not comfortably) in the real world. According to the Self-Sufficiency Standard, a family with two parents in Washington, DC, both working full time, with a preschooler and a school-age child, would have to earn at least $9.78 per adult per hour to cover costs with no public or private support. In the city of Boston, the same family would need to earn $10.08 per adult per hour. Bear in mind that the minimum wage is currently $5.15 an hour, which explains why, in this country, we have tens of millions of people in a category known as the “working poor.”
This is not simply an argument for raising the minimum wage. It is instead a call for putting in place government programs to supply to the poor the basic necessities of a decent, healthy life. Every other industrialized nation has, for example, a national health care program so that none of its citizens are socially excluded from access to reliable, affordable, medical care. It is time for this and similar programs to be created or expanded here in the US.