LETTERS TO THE EDITOR Assoc. 2005;97:206-21 1. 2. Hellerstein HK, Friedman EH. Sexual activity in postcoronary patients. Arch Intem Med. 1970;125: 987-999. 3. Friedman EH. Music and neuroscience (letter). NY Acad Sci Magazine Update. April/May 2004. 4. Friedman EH. Neurobiology of decreased heart rate variability in older patients with recent acute coronary syndrome (READERS' COMMENTS). Am J Cardiol. 2004;94:1479. 5, Shriberg E, Bates R, Stolcke A, et al. Can prosody aid the automatic classification of dialog acts in conversational speech? Lang Speech. 1998;41:443-492. 6. Tremblay KL, Kraus N. Auditory training induces asymmeMcal changes in cortical neuronal activity. J Speech Lang Hear Res. 2002;45: 564-572. 7. Russo N, Nicol T, Zecker S, et al. Auditory training improves neural timing in the human brainstem. Behav Brain Res. 2005;156:95-103.
ing health disparities, as we speculate that social injustices (including racism/discrimination)2'8 play a great part in the web of causation contributing to health disparities.
Ernest Friedman
[email protected]
Approaching Health Equity To the Editor:
The complex and perplexing problem of health disparities is a topic that has gained widespread attention from public health researchers and professionals. Ergo, we were intrigued when reading Green and colleagues" recently published article, "Reducing and Eliminating Health Disparities: A Targeted Approach," in the January 2005 edition of the Journal of the National Medical Association. The authors of the article present a pragmatic approach for eventually eliminating health disparities that goes beyond boilerplate solutions. The historical references highlighting that health disparities have long been documented not only indicate the persistence of the disproportionate burden of noxious health outcomes but highlight the enormous battle of actually ameliorating and ultimately eliminating health disparities. We applaud the authors for noting the vital role social justice plays in perpetuat-
As noted by the Green et al.,' health promotion interventions designed to close the gap in health outcomes are useful if based on sound theoretical models; but many of these constructs have limitations.9 Stokols' social ecology theory and Maslow's hierarchy of needs (as discussed in the article) may be applicable models for disparity interventions because they incorporate multidimensional approaches, recognizing the contextual factors that affect health. Evidence indicates that contextual factors influence health; for example, physical and social environments often affect one's health.'0"' The article stresses the need for systemic changes, including health and social policy changes, as well as the need for interdisciplinary and innovative strategies to eliminate health disparities-all of which we support. The authors provide a comprehensive list of recommendations, as well as the anticipated challenges in implementing them. The authors also emphasize access or lack of access to healthcare as a contributing factor in health. Howev-
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er, others have shown that improved healthcare access have only minimally affected health disparities.12 We believe that while healthcare access plays some role in health disparities, structural factors, such as social structure inequalities (especially racism/discrimination),2-8 are far greater influences in perpetuating health disparities. We strongly believe that to mitigate health disparities, as observed in the article, there needs to be improvement in racial/ethnic minority, lowincome and other socially disadvantaged groups' status in society. Moreover, we strongly feel that community-based participatory research may be one the best methods to impact differentials in health.13-15 We suggest more emphasis on the primary prevention of disease as a tactic to reduce inequities in health. To eliminate health disparities a continued sense of urgency is needed, as well as theory-based interventions and multidisciplinary approaches. To reach the national ambitious plan of reducing health disparities by 2010 immediate action and changes need to be implemented. In sum, Green et al.'s' article provides researchers and policymakers alike with pragmatic recommendations and the challenges inherent in eliminating health disparities. This article may be helpful to those interested in making substantial inroads in health disparities. Dustin T Duncan Department ofPsychology, and Public Health Sciences Institute, Morehouse College, Atlanta, GA and Social Epidemiology Research Center Department of Community Health and Preventive Medicine Morehouse School ofMedicine Atlanta, GA dduncan39@,hotmail. com VOL. 97, NO. 4, APRIL 2005
LETTERS TO THE EDITOR
Rakale Collins Quarells, PhD Social Epidemiology Research Center Department of Community Health and Preventive Medicine Morehouse School ofMedicine Atlanta, GA Dionne J Jones, PhD, MSW Services Research Branch Division ofEpidemiology Services and Prevention Research National Institute on DrugAbuse National Institutes ofHealth, Bethesda, MD and Psychology Department School ofUndergraduate Studies University ofMaryland University College Adelphi, MD
REFERENCES 1. Green BL, Lewis RK, Bediako SM. Reducing and eliminating health disparities: a targeted approach. J NatI Med Assoc. 2005;97:25-30. 2. Bennett GG, Wolin KY, Robinson EL, et al. Perceived racial/ethnic harassment and tobacco use among african american young adults. Am J Public Health. 2005;95:238-240. 3. Bennett GG. Health Disparities. In: Anderson NB, ed. The Encyclopedia of Health and Behavior. Thousand Oaks, CA: Sage Publications; 2004. 4. Din-Dzietham R, Nembhard WN, Collins R, et al. Perceived stress following race-based discrimination at work is associated with hypertension in African Americans. The metro Atlanta heart disease study, 1999-2001. Soc Sci Med. 2004;58:449-46 1. 5. Mustillo S, Krieger N, Gunderson EP, et al. Selfreported experiences of racial discrimination and black-white differences in preterm and low-birthweight deliveries: the CARDIA Study. Am J Public Health. 2004;94:2125-2131. 6. Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrmination and health: findings from community studies. Am J Public Health. 2003;93:200-208. 7. Clark R, Anderson NB, Clark VR, et al. Racism as a stressor for African Americans: a biopsychosocial model. Am Psychol. 1999;54:805-816.
8. Kreger N, Sidney S. Racial discrimination and blood pressure: the CARDIA Study of young black and white adults. Am J Public Health. 1 996;86:1 370-1378. 9. Institute of Medicine. Health and Behavior: The Interplay of Biological, Behavioral and Societal Influences. Committee on Health and Behavior, Research, Practice and Policy, Board on Neuroscience and Behavioral Health. National Academy Press: Washington, DC. 2001. 10. Kawachi 1, Berkman LF, eds. Neighborhoods and Health. New York: Oxford University Press. 2003. 11. Berkman LF, Kawachi 1, eds. Social Epidemiology. Oxford: Oxford University Press. 2000. 12. Smedley BG, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press. 2002. 13. Blumenthal DS, Yancey E. Community-Based Research: an Introduction. In: Blumenthal DS, DiClemente RJ, eds. Community-Based Health Research: Issues and Methods. New York, NY: Springer Publishing Co. 2004. 14. Findley S, lrigoyen M, Sanchez M, et al. Community empowerment to reduce childhood immunization disparities in New York City. Ethn Dis. 2004;14(3Suppl 1):S134-S141. 15. Horowitz CR, Arniella A, James S, et al. Using community-based participatory research to reduce health disparities in East and Central Harem. Mt Sinai J Med. 2004;71:368-374.
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