Howard Straker, PA, MPH

Assistant Professor
Department of Physician Assistant Studies
School of Medicine and Health Sciences
Department of Prevention and Community Health
Milken Institute School of Public Health
The George Washington University, Washington D.C.
hstraker@gwu.edu
Office: (202) 994-7727

Adapted from Cherise Harrington, PhD, MPH

 On a piece of paper answer the question

 “Who are you?”

◦ Write a list 5 things that DEFINE who you are (that

you are willing/comfortable sharing).
 Introductions
◦ Name
◦ Track/Department
◦ Educational Background
◦ What you want to be when you grow up?
◦ Tell us something interesting about yourself

◦ Name your five things (if comfortable)

◦ How many listed race/ethnicity?
◦ How many listed religion/faith?
◦ How many listed marital status?
◦ How many listed student/occupation/vocation?
◦ What other types of things did you list?
 People identify themselves in varying ways

 For some groups of people race/ethnicity is at

the forefront of daily life/self-identity

 Respecting the role that group identification

plays in an individual’s identity is important

 Describe how/why racial/ethnic, educational,

income-related differences should not suggest
hierarchy

 Explain that any of these characteristics/qualities

may directly or indirectly impact your health
 In this class we will
◦ 1. Examine attitudes (mistrust, subconscious bias,
stereotyping)

◦ 2. Gain knowledge of the existence and magnitude

of health disparities

◦ 3. Acquire skills to effectively understand, respect,

communicate, collaborate, and intervene
 Expecting one individual to “represent the views”
of their ethnic (or any other self-identified) group

 Assuming that experiencing

discrimination/racism makes one immune to
holding stereotypes or having biased views of
minority or non-minority groups

 Thinking of health professionals as either “saints”

or “sinners”, rather than human (ignorance vs.
malice)

 Using a broad brush to characterize people and

their political views.
 Assignments/evaluation
◦ Discussion piece: Several of the sessions have assigned
“Discussion pieces”. Please review the assigned
discussion piece and prepare a discussion question
based on the reading to present to the class.
Additionally, please prepare to answer your classmates’
questions.

◦ Team debates: Teams will debate pre-assigned topics.

A debate and grading rubric will be provided.

◦ Midterm Exam: You will complete a take-home, open-

book exam. You will have 7 days to complete it.

◦ Team Final Presentation: You will complete a team based

final presentation. Logistics and grading rubric will be
distributed.
 All group members are expected to participate
in the research, development, and
presentation of your debate position.
Preparation will require substantial library
research.
 Outlines
◦ Each participating member will receive the same
group grade. Each Group Member Must Present**
◦ Position Presentation – Pro/Con (10 minutes)
◦ Preparing for Rebuttal (10 minutes);
◦ Rebuttal – Pro/Con (5 minutes)
 Debate Groups/Topics
Debate Pro Con Issue

2/7 Team 1 Team 2 Individuals who engage in unhealthy behaviors or lifestyles

(discuss both smokers, overweight/obese) should pay more in
health insurance and pay higher taxes.
2/14 Team 3 Team 4 Individuals should be tested for drugs prior to receiving
government assistance,
2/21 Team 5 Team 6 Zoning laws should exist to limit the number of fast food places
and liquor stores in low income areas.

2/28 Team 7 Team 8 Participation in educational programs targeting health behaviors

like shopping/eating healthy should be mandatory for those
receiving government assistance.

TEAM 1 TEAM 2 TEAM 3 TEAM 4 TEAM 5 TEAM 6 TEAM 7 TEAM 8

Henne Begun Aysola Berry Graham Aluc Picard Drame

Kansal Parker Johnson Madrid Harris Baskerville Scudder Hunter

Langelotti Wu Ward Voight Stepp Flores Wallace Tran

Maizel
 Each student must complete a take-home exam.

 This exam will assess your level of comprehension of

key issues in health disparities, your ability to
conceptualize a problem and a workable solution, in
addition to evaluating a program.

 You will have 1-week to complete the exam once it is

posted on February 28th, it is due by 11:59pm,
March 8th.

 Blackboard submission, please name the file

“LastName_FirstName-Midterm Spring 2017”.
 Teams of 3-4.

 You will have 15 minutes to present your project (12 minute

presentation, 3 minutes for questions). Your presentations will be
on the last day of class.

 Please submit slides to the instructor. Get creative and find

something that you feel passionate about. As discussed in class,
make sure to present your information as it relates to a specific
group. See Blackboard for instructions and grading rubric.

 Final Presentation Examples: Gentrification (discuss impact on a

specific community, do not merely discuss overall gentrification
implications), Gun control laws, State minimum wages, Education
spending, DOMA, Abortion laws, Housing policies
 Define health disparities

 Discuss contributors to health disparities

 Understand how race and privilege impacts

health disparities

 Understand how the U.S.’s history (race

relations) directly relates to health disparities
for some groups
http://healthpowerforminorities.com/special-
channels/major-killers/
The main determinants of health include:

 Background (demographics, family history)

 Behavior and lifestyle

Personal
Responsibility
 Environmental exposure
vs.
 Healthcare (access, preventative care, insurance
Social
type, etc.) Inequalities

*Each of these are linked to health disparities…

directly or indirectly
 For every $1 spent, .05 cents goes to
prevention

 U.S. healthcare is market commodity vs.

human right

 Value system Who decides?

Health Disparities
 Health disparities are broadly defined as the
difference in disease linked to demographic
characteristics (e.g., age, race, ethnicity,
gender, and sexual identity) and
socioeconomic factors (e.g., income,
education, and geographic location).
 Incidence

 Prevalence

 Mortality

 Burden

 Access to care

 Care quality
DISPARITIES DIFFERENCES

 Differential treatment for  Skiers more likely to

fractures based on have fractures
race/ethnicity
compared to non-
skiers
 Girls in some countries
less likely to be
immunized  Young adults are
healthier than older
 Differential treatment for adults
some cardiovascular
conditions based on race
and gender
 Unfair differences

 Systematic and plausible avoidance

 Adverse health in socially disadvantaged

group

 Terms:
◦ Equity - value based (goal)
◦ Disparity - matrix of measurement

 Disparities -- Equality -- Equity

 Racial/ethnic groups
 Low income
 Low Educational attainment
 Immigrants
 Elderly
 Disabled (Intellectually and Physically)
 Gender-based
 Military
 Location-based (rural vs. urban)
 LGBTQ (Sexual minorities)
 The social determinants of health are the
conditions in which people are born, grow,
live, work and age, including the health
system.

Source: Dahlgren and Whitehead, 1991

 Race/Ethnicity  Insurance status
 Socioeconomic Status  Employment status
 Gender  Geographic location
Racism
Sexual Identity 

 Discrimination
 Disability
 Bias
 Stereotypes
 Ignorance

Non-modifiable Modifiable (theoretically)

 History

 Individual behaviors*

 Individual/population beliefs/bias
◦ Racism

 Social/political climate (past/present)

 Environmental
 Aspects of U.S.’s history and development are
directly related to the health of its citizens

◦ African-Americans

◦ Native Americans

◦ Immigrants

◦ Income and education

 Poor vs. rich
 Educated vs. uneducated
 Insured vs. uninsured
 Jim Crow Laws 1830-1960s – Set stage for
proliferation of Health Disparities

 Plessy vs. Ferguson 1896– upheld separate

but equal

 Hill Burton Act – Equal facilities with federal

funds

 Current examples? (e.g., ELS school policy)

 Integration/Segregation
◦ Segregation - associated disinvestment
◦ Shaped by past and present housing policies

 Resources

 Access
 Deservedness - May manifests as "bias" to
people of color and the subsequent
decreased likelihood to support programs
that benefit a group
Race and Privilege
 Race, class, and gender are part of the whole
fabric of experience for all groups

 Complexity of social relations, social issues,

and social justice is infused with race, class,
and gender

 The less a person has in society, the more at

risk that person is for health and social
problems

 Racism = prejudice plus power

Institutionalized
 Material conditions and access to power
 Differential access to information
 Includes one’s history, resources, and voice
 Differential representation in government
and the media

 Ex:
◦ Differential access to quality education
◦ Adequate housing
◦ Gainful employment
◦ Appropriate medical facilities
◦ A clean environment
Personally-mediated (Individual) racism
 Prejudice
 Discrimination
 Stereotypes
 Judgments based on assumptions about the
abilities, motives, and intentions of others
according to their race

 Manifests as lack of respect, suspicion,

devaluation, scapegoating, and
dehumanization
Internalized Racism
 Characterized by one’s own belief in the
negative messages received about one’s own
race or ethnicity.
 “An oppressive society re-creates itself in its
victims’ hearts”
 Addresses subjectivity, questions power, and
the part each person plays in the evolution of
his or own life story
 Important to confront experience of privilege
that accompanies being dominant race.

 Dominant race often serves as point of

reference, the norm, and is compared to those
disadvantaged individuals along a continuum of
oppression and powerlessness

 Omi 2000 “Whites tend to locate racism in color

consciousness and find its absence in color-
blindness. In so doing, they see the affirmation
of difference and racial identity among racial
defined minority students as racist. Black
students, by contrast, see racism as a system of
power, and correspondingly argue that they
cannot be racist because they lack power.”

 “Racial Tax”
 Social construct not
biological

 Inconsistently defined and

measured
◦ However in most cases the best
proxy measure for interaction
of social and health factors

 MP & HPg 28 Conceptual

model of race
◦ Latent Factor (race)
◦ Manifest Indicator (skin color)
◦ Categorization into risk
behavior groups
◦ Risk exposure
◦ Observed health outcome
 Social construct not  Social vs. biological
characteristics (note
biological race-related US History)
 Legacy of oppression
 Self-determined
 Evident across the life
span
 Inconsistently defined
and measured  Evident across multiple
diseases

 Role of ethnicity  Increase risk = Increased

prevalence and incidence

Characteristics of Race Disparities linked to race

 Easily defined (income,  Social
occupation, education)

 Easily measured  Evident across the life

span
 Measureable burden
 Evident across multiple
 Determines where, how, diseases
and under what
circumstances one lives
 Increase risk =
 Clearly predicts health Increased prevalence
status and incidence

Characteristics of SES Disparities linked to SES

 Persons with incomes of less than $10,000
were 3.22 times more likely to die of any
cause than were those with incomes over
$30,000.

Low Income, Not Race or Lifestyle, Is the Greatest Threat to Health

http://www.rwjf.org/reports/grr/026422.htm
 Often misunderstood…when income is taken
into account, behavioral risk factors such as
smoking, alcohol drinking, sedentary
lifestyle, and obesity accounted for only a
small proportion of differences in mortality
across sex, race, and age groups.

 While income loss had the greatest impact on

mortality among middle-income individuals,
persistent poverty was the strongest
predictor among low-income persons.
Low Income, Not Race or Lifestyle, Is the Greatest Threat to Health
http://www.rwjf.org/reports/grr/026422.htm
 If SES is a more reliable measure, why don’t
we use it instead of race to categorize
groups?
Race
• In most cases race is the best proxy
measure/construct for the interaction of
social and health factors
 Education and especially income matter to health
status

 Racial differences in health are markedly, but not

wholly, explained by income.

 Perceived discrimination and race-related stress

also play considerable role.

 Persistent low income can be an especially good

predictor of mortality regardless of race.
Low Income, Not Race or Lifestyle, Is the Greatest Threat to Health
http://www.rwjf.org/reports/grr/026422.htm
 Not to tell you what to think but how to think!

 Teach you how to consider context

 Teach you how to self-evaluate

 Fine tuning your “hey that goes against my

human/public health sensibilities” or more
aptly “bull crap” meter
https://www.youtube.com/wa
tch?v=H0yP4aLyq1g