Growing evidence documents profound disparities in health between affluent and socioeconomically disadvantaged and white and black Americans.1–5
Compared with the majority of the American population, the poor and racial and ethnic minorities in the USA have reduced life expectancy and higher mortality and disease rates from diabetes, asthma, heart disease, stroke, hypertension, poor birth outcomes, and some cancers.6
In the USA, the life expectancy gap between the best off and the worst off is reported to be 15.4 years for males and 12.8 years for females.7
This disparity in mortality is due primarily to chronic diseases resulting from exposure to known environmental risks such as air pollution and occupational hazards and to health-damaging consumer products such as tobacco, alcohol, and high-calorie high-fat foods.8
Since 80% of the US population lives in metropolitan areas and cities concentrate poor people and income inequalities, these disparities in health are most heavily concentrated in urban areas.
Since the 1985 release of the Heckler Report,9
the first federal acknowledgement of racial/ethnic disparities in mortality, eliminating these inequities has been an important priority of many government and nonprofit agencies.10–12
Yet there has never been a comprehensive well-coordinated strategy for accomplishing this goal nor a national framework to coordinate research and policy or to translate detection of differences in disease burden into public health and medical practice.
It is therefore not surprising that, more than 20 years after the Heckler Report, disparities in life expectancy and rates of death and illness from many conditions persist and are in some cases widening.1
Economic trends such as increasing poverty and unemployment rates, dismantlement of safety net programs, the decline of well-paying US manufacturing jobs that traditionally provided health care benefits, and the shift of health care costs from employers to workers suggest that these disparities will continue to grow.
The variability of disease incidence among US populations suggests that, by identifying the avoidable causes of these differences, it may be possible to develop strategies to mitigate their effects. Common explanations for disparities in health include differences in genetic predisposition, access to health care, socioeconomic and behavioral characteristics, cultural preferences, exposure to environmental hazards, or some combination of these.1–6,13,14
At the present, we can do little to modify the effects of genetics on human health,15
and modifying individual behaviors and cultural practices sufficiently to influence population health has proven to be difficult.16
Therefore, progress in eliminating disparities in health requires that we look upstream to social and environmental factors that are amenable to intervention through public policies.
Recently, policy makers have focused on reduced access to health care as an important modifiable contributor to the poor health of socioeconomically disadvantaged and minority Americans.17–19
Here, we make the case for reducing the disproportionate exposure to environmental and consumer hazards as another promising strategy for eliminating health disparities.
In the last three decades, US researchers have produced solid evidence on the health impact of exposure to environmental risks such as air pollution, lead, and hazardous wastes20–22
and to consumer products such as tobacco, alcohol, and unhealthy food.23–25
In many cases, the government has instituted regulatory and consumer protection policies that could reduce the burden of these exposures, offering added benefits to the disenfranchised, primarily urban, populations that are most exposed. The problem, in our view, is twofold. First, many environmental and consumer protection policies are not adequately or equitably enforced and, second, the regulatory approaches developed in the last century have not been updated to protect against current threats. Thus, our policy prescription for reducing disparities is to enforce existing policies more vigorously and equitably and to use scientific advances in the understanding of disease causation to modernize our approach to regulation.