I recently wrote to celebrate Amal Trivedi and colleagues finding of decreasing racial and ethnic differences in the quality of care in US hospitals. In The Atlantic, James Hamblin reads the same study and takes another view. He makes two important points:
- In many areas of preventive care, typically those delivered in ambulatory settings, racial and ethnic disparities remain large.
- More importantly, differences between US racial and ethnic groups in health, not health care, remain large.
I completely agree.
But I don’t agree with what follows. Hamblin ends his essay by quoting his interview with Marshall Chin,
compared to 10 years ago, we actually know a lot about how to reduce disparities [in health]. At this point it’s basically about having the national will to make reducing disparities a priority.
There are two assertions here: first, that we have interventions that, if we used them, would change the social determinants of health. If having interventions means having good evidence that the interventions work, then I’m skeptical. Our evidence for most clinical interventions is often sketchy. We have much less evidence about interventions to change the social determinants of health.
The second assertion is that what stands in our way is the lack of political will to address the social determinants of health. Oh, is that all? Have Hamblin and Chin noticed that since 2009, we have been engaged in a political struggle merely to reduce the number of uninsured and that it is far from clear that we will win even that?
The New Year is for looking ahead. Taking the long view, I am with Hamblin and Chin: health outcomes matter more than health care and to change outcomes we must change the social determinants of health. Yet in 2014, I was often near despair about the prospects for justice in health and health care. See, for example, Austin and my discussion of the fate of the ACA in Mississippi; or Nicholas’s or my comments on King v. Burwell. How do we face the difficult prospects of the next few years?
By resolutely maintaining both the commitment to seeing things as they are and the struggle to transform them to how they should be. Here is a quote from James Baldwin:
It began to seem that one would have to hold in the mind forever two ideas which seemed to be in opposition. The first idea was acceptance, the acceptance, totally without rancor, of life as it is, and men as they are: in the light of this idea, it goes without saying that injustice is a commonplace. But this did not mean that one could be complacent, for the second idea was of equal power: that one must never, in one’s own life, accept these injustices as commonplace but must fight them with all one’s strength. This fight begins, however, in the heart and it now had been laid to my charge to keep my own heart free of hatred and despair.
Here I will register one more disagreement with Hamblin. He wrote that
So [Trivedi’s finding of reduced health care disparities] is technically improvement, and it will be reported as improvement, but it’s… a reduction in injustice, not cause for celebration.
A reduction in injustice is a cause for celebration. To keep our hearts free of hatred and despair in 2015, we need to celebrate progress toward justice whenever we find it.