Tuesday, August 18, 2009

Racial Disparities in Boston Swine Flu

Health status differs by race and ethnicity. This is not news to people working in the health arena, in fact an entire department of the Boston Public Health Commission is focused on reducing racial health disparities. Often such inequities in health are assumed to be a result of genetic differences or differences in income or socioeconomic position. However, social and environmental factors are also an important consideration.

The latest racial health disparity to reach the front page of the Boston Globe is the increased prevalence of swine (H1N1) flu cases among African Americans and Hispanics in Boston. Stephen Smith of the BG reported that H1N1 cases are clustered in neighborhoods with a high proportion of residents of these racial and ethnic backgrounds.

Dorchester, Roxbury, and East Boston were particularly hit hard this Spring and Fall by the swine flu. Why might this be the case? The two theories presented in the BG report include:
  1. Crowded living conditions -- densely populated areas may precipitate the conditions needed for person-to-person transmission of the virus.
  2. The composition of the local public schools -- the over-affected neighborhoods have a large Hispanic and immigrant school-aged population may have facilitated the spread of the virus in these communities.
These two theories represent the major challenge of social epidemiology. Are health differences a result of the people? or the place?

If the increased prevalence of H1N1 among African Americans and Hispanics is due to the people, then changes to living conditions would have no effect on the residents' health. If the increased prevalence is due to living conditions, then why try to change individuals' knowledge or behaviors? Activities targeting people would have no impact.

Likely the reason for increased risk of swine flu among these racial/ethnic groups is a combination of the two. Hispanics may be more likely to have recently traveled to or been in contact with someone who was in a high-prevalence area (such as Mexico City) or those most affected may have less knowledge of flu prevention activities. On the other hand, housing conditions and other neighborhood characteristics (lack of health care/vaccine access, less penetration of media messaging on how to prevent flu, etc) may have resulted in the heightened risk.

These hypotheses are even more complicated since residents in the over-affected Boston neighborhoods are also at higher risk for a variety of health issues that could compromise their immune systems, increasing their susceptibility to more severe cases of the H1N1 virus. Are those other health issues due to the people? Or the place?

The answer to that question has important implications for the type of prevention programs and actions that will be taken in the coming months to prepare for flu season. Would you try to change individuals' behaviors and raise awareness? Or would you tackle the social and built environment?

Resource constraints make it difficult, if not impossible, to attack every issue from all sides - which would you prioritize and why?

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