CONTENTS INTRODUCTION I. HEALTH DISPARITIES, CONSTRAINED CHOICE, AND INTERSECTIONALITY A. Morbidity & Mortality Disparities B. Constrained Choice C. Intersectionality II. GUIDING PROPOSITIONS OF AN INTERSECTIONAL CONSTRAINED CHOICE APPROACH TO HEALTH DISPARITIES A. Neighborhood Effects B. The Role of Allostatic Load C. Exploring the Cases of CVD & HIV/AIDS 1. Biological Background on CVD 2. CVD Epidemiology in African Americans 3. Biological Background on HIV/AIDS 4. HIV/AIDS Epidemiology in African Americans 5. The Role of Neighborhood in CVD & HIV/AIDS 6. The Role of Allostatic Load in CVD & HIV/AIDS. III. IMPLICATIONS & ACTIONABLE STEPS A. Implications B. Actionable Steps 1. Research Steps 2. Public Health Steps 3. Steps to Alleviate the Effects of Income Disparity CONCLUSION INTRODUCTION
In the United States, race-based health disparities are well documented and persistent, as are their profound impact on morbidity, mortality, and well-being for African Americans. Measuring and, to a lesser extent, addressing these disparities has been a central focus of social science, medical, and public health research. Researchers have explored a variety of factors related to health including, but not limited to, socioeconomic status (SES) and employment. Other barriers to care include access, geographic differentials, and provider discrimination. While each of these approaches has explained some component of race-based health disparities, studies are often limited by a narrow focus that is insufficient in the context of additional statuses such as gender and sexual orientation. Consequently, intersectionality theorists and researchers (1) employ a framework that captures the ways in which these statuses combine and interact in order to assess how they contribute to the structure of opportunity and health outcomes across society. Health disparity literature is somewhat weaker in the area of providing concrete, actionable steps that may be taken to remedy these disparities.
Constrained choice--a theory that explains gender-based health disparities and offers actionable steps for rectifying these disparities (2)-- addresses how the complex interplay between social structures, social institutions, and social policies shape individual agency in pursuing health and health outcomes. (3) The differential opportunity to pursue health affects biological risk through stress exposures and acquired dysregulation of key biological systems (the loss of the ability to maintain each system within normal, healthy ranges), which is itself compounded by differential access to health care. Intersectionality provides a lens through which to address the complexities of the illness experience for different sectors of the African American community. (4)
In this article, we use a constrained choice approach that is informed by intersectionality to systematically explore how the interplay of individual agency with social policy and social institutions creates and maintains race-based health disparities. We illustrate how the statuses of race, gender, and sexual orientation further shape these disparities through an examination of cardiovascular disease (CVD) and human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS). We begin with a brief review of the literature on health disparities, constrained choice, and intersectionality. Our approach explores the roles of the social and built residential neighborhood environment and acquired physiologic dysregulation (measured by allostatic load) as areas of commonality across the two diseases. We then provide a review of the biological etiology of CVD and HIV/AIDS and a review of disparities in morbidity and mortality including the role of neighborhood and allostatic load for each condition. Finally, we offer actionable steps to address these social disparities and alleviate the health disparities that they create.
Racial disparities play out profoundly in CVD and HIV/AIDS. CVD is the leading cause of death in the United States and although mortality has dropped for other populations in recent years, CVD death rates for African Americans have remained the same as they have been since 1950. As a result, African Americans are 1.6 times more likely to die of CVD than non-Hispanic whites. (5) While overall incidence of HIV/AIDS in the United States remains low, prevalence rates have reached epidemic proportions in certain populations and geographic locations. (6) For example, although African Americans make up only 12 percent of the U.S. population, they make up 44 percent of all new HIV infections each year, thus making HIV/AIDS a leading cause of death for African American men and women. (7) While CVD and HIV/AIDS have very different biological etiology, disease course, and prognosis, the patterns of disparities for both conditions leads to excess morbidity, disability, and mortality. Moreover, an examination of each reveals that they share underlying social-structural determinants. We argue that the neighborhood context and the allostatic load create an interwoven set of challenges to agency that contribute to health disparities.
Our discussion of racial disparities is limited here to an examination of African Americans compared to non-Hispanic whites. A broader examination is hindered by the paucity and inconsistency of data on CVD and HIV/AIDS in other racial and ethnic groups. Moreover, the complexity of an intersectionality approach necessitates a focus on two racial groups in order to adequately address other statuses. Toward that end, we consider four other statuses in this analysis: gender, SES, sexual orientation, and geographic location. Finally, we focus on disparities in morbidity and mortality while briefly touching on related topics including disabilities, disparities in health care access, and quality of care.
HEALTH DISPARITIES, CONSTRAINED CHOICE, AND INTERSECTIONALITY
In this section we address some of the major patterns of health disparities across different populations within the African American community. We also draw on a variety of perspectives and theories to explain these disparities. We end this section with a discussion of constrained choice and intersectionality and how these paradigms inform an understanding of health disparities.
Morbidity & Mortality Disparities
Race is a highly problematic social construct given that there is greater genetic variation among individuals within a racial group than among individuals across racial groups. (8) Racial categories differ across societies while also shifting considerably over time. Yet, the social, economic, and legal consequences of racial discrimination remain real. (9) These realities guide this discussion of race-based health disparities. As noted by Williams and Jackson, "race is a marker for differential exposure to multiple disease-producing social factors. Thus, racial disparities in health should be understood not only in terms of individual characteristics but also in light of patterned racial inequalities and exposure to societal risks and resources." (10)
The disparities in life expectancy for African Americans and non-Hispanic whites are well documented and persistent. (11) In 2010, African American males at birth had a life expectancy of 71.8 years compared to 76.5 years for non-Hispanic white males. Mortality advantage is also pronounced among non-Hispanic white women. Non-Hispanic white women have a life expectancy of 81.3 years compared to 78.0 years for African American women. (12) Similarly, infant mortality rates are considerably higher for African American women with 11.46 deaths per 1000 live births compared to only 5.18 for non-Hispanic white women in 2010. (13) Beyond life expectancy, African Americans have higher rates of morbidity, mortality, injury, and disability than non-Hispanic whites. (14)
Fundamental cause theory posits that SES is the primary factor that shapes individual health and related health disparities. (15) While lower SES is a consistent predictor of mortality disparities, (16) a comparison of health outcomes for African Americans and non-Hispanic whites of the same SES reveals that African Americans have notably worse health outcomes. (17) Murray and colleagues demonstrated that race, residential location, population density, race-specific income, and homicide rates were all associated with lower life expectancy for African Americans compared to non-Hispanic whites. In other words, multiple social disadvantages and exposures compound socioeconomic disparities in health. (18)
Within the African American population, we consider the subgroup of sexual minorities. While there are many different sexual minority groups, the three groups included in our analysis are defined in public health and medical literature as men who have sex with men (MSM), women who have sex with women (WSW), and male to female transgender persons (MTF). Research on health and health disparities faced by African American sexual minorities is still in its infancy. Among sexual minorities, much of the research on health disparities has focused on the negative impact of HIV/AIDS on life expectancy for MSM. (19) Indeed, many researchers have persuasively argued that this focus has led researchers and the general public to at times view MSM in general, and black MSM in particular, as not only stigmatized but even inherently diseased. (20) In addition, sexual minorities as a whole face specific, increased health risks associated with how they are viewed in society, often confounded by socioeconomic and other disparities associated with race. For example, while all transgender people regularly encounter extremely high rates of sexual assault, (21) physical violence, (22) and murder, (23) MTF transgender people of color are disproportionately affected. (24)
Societal problems such as segregation, poverty, racism, homophobia, and transphobia can cause emotional and physical stress to...