Voice: Amitabh Chandra

Amitabh Chandra is professor of public policy at Harvard and director of health policy research at the Harvard Kennedy School of Government.

“These disparities are real. Anybody who says, ‘Well, these disparities don’t exist,’ is living in denial. But people disagree. Where people who study this disagree it’s on what drives these disparities. Without giving you my world view, the permanence of these disparities are principally things like differences in behaviors, differences in neighborhoods, differences in early childhood circumstances and schooling, and then differences in healthcare and health insurance.”

Now my own view is that healthcare and health insurance are important. But when you’re talking about life expectancy, and you’re talking about people’s health, the social determinants of health are far more important than the healthcare determinants of health. Unfortunately, a lot of the literature has zoomed in on the healthcare determinants of health, and they’ve noted that when you’re looking at the healthcare disparities – not health disparities, healthcare disparities – how often do you get a flu shots, do African-American patients get preventive care as often as white patients do, and there is a disparity there, too. And there is a thinking in the literature, gee, if we could only shut down the disparities in healthcare and insurance then we could shut down the disparities in health.

Amitabh Chandra

Amitabh Chandra

And I think that’s an astonishingly naive position to have, because healthcare is one of the many, many determinants of health. The role of neighborhoods. The role of socio-economic status. The role of behaviors. Behaviors like the diet I have, the compliance and adherence I have with prescription drugs. These things are far more important than the cause and effect of healthcare on health, for the very simple reason that health care comes in in the end.

So what does that mean? It doesn’t mean that disparities don’t exist. But what we should really be focusing on are disparities in socio economic status, and where those originate from. And I think they originate very early in life. I think schooling and child enrichment programs for minority students in minority neighborhoods – that’s what we should be interested in.

Something like racial disparities in early mortality – like premature mortality, dying before the age of 65. It should not happen. In America, no one should die before the age of 65. It should not happen. When I see that happen, it jars me in a way that no other fact on disparities jars me. You know what I mean? It’s a weird thing to say, but suppose you told me there was a seven-year difference in life expectancy – that African Americans lived to 90 and majority groups lived to 97, I would say that is astonishing. That is an astonishing disparity. But on the other hand I would also drop back and say, wow, everybody at least got to live to be 90. But when a group of people dies before 65, it just gets to me. It’s a wakeup call.

Childhood obesity, children wearing safety belts, that’s what we should be thinking about. Juvenile diabetes – early evolution of the racial test-score gap in kindergarten. Those are the things that really bother me. We know that reading begets reading, skill begets skill in school. I think about myself. If you fall behind reading in kindergarten, 1st grade, that gap is just going to grow and compound itself by the time you’re in 2nd grade. It’s going to become even larger by the time you’re in 3rd grade. And it’s very hard to come back in at the level of college, and say, well, we’re going to do affirmative action, we’re going to have all this financial aid for minority students – it’s too late. It’s too, too late.

I think the childhood component is important. But the one thing that we can give people is we can give them the promise of later opportunity. In the absence of later opportunity, in the absence of people knowing that there’s opportunities waiting for them, and the world is fair and will reward people with good ideas – in the absence of knowing that, it is going to be very hard for us to get a lot of these kids to wear their safety belts, or to make the conscious investments we need to make. Because if all they see is a very bleak future waiting for them, then why would make they those investments? It’s actually rational not to.

Think about the world as a very uncertain place. So I’m 40 years old, but I just thought random things are going to happen to me at 40, 41, 42, that I could be laid off, that I could be hit by a bus, that I could get cancer, or have a heart attack or stroke, be thrown in jail, detained by the police – these things would happen regardless of whether I’m a good person and did the right things: Work hard or not, why would I invest in any of the good behaviors? You might as well take up smoking.

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