Health Care and the Oppression Narrative

County health rankings. Source: Robert Woods Johnson Foundation

Correlation does not equal causality. That’s a fundamental tenet of statistics, but the concept apparently is so rarefied that a Virginia Mercury article based the Robert Wood Johnson Foundation’s County Health Rankings appears to be unfamiliar with it. The result is a headline — “In Virginia, health outcomes follow geographic and racial lines” — that has become standard fare in the ongoing Oppression Narrative embraced by most of Virginia’s media outlets. By misdiagnosing the problem, the Oppression Narrative does a grave dis-service to Virginia’s poor and minorities.

Writes the Virginia Mercury today:

More than 20 percent of Virginia’s black, American Indian and Hispanic populations report poor or fair health, compared to 14 percent of the state’s white residents. …

Year over year, the rankings essentially tell the same story: Virginia’s healthy counties, many of which are nestled in the northern part of the state, remain healthy, while its unhealthy localities, clumped together in the south and southwest, continue to struggle with poor outcomes. …

The article continues:

“There are significant differences in health outcomes according to where we live, how much money we make, or how we are treated,” the report states.

“There are fewer opportunities and resources for better health among groups that have been historically marginalized, including people of color, people living in poverty, people with physical or mental disabilities, LGBTQ persons and women.”

To be sure, there are differences in access to health care that vary by geographic area. As a rule, access is better in Virginia’s affluent metropolitan areas than it is in poor rural areas. However, it is not clear from the Robert Woods Johnson Foundation (RWF) data how much of better health can be attributed to differences in access to treatment and how much to differences in the prevalence of risk factors such as obesity, diabetes, smoking, substance abuse, and unsafe sex.

The RWF reports discusses those factors at some length. The Virginia Mercury article totally ignores them. But even the RFW methodology has problems. We must delve into the details in order to see how the presentation of statistics can be more biased than readily meets the eye.

The RFW health factors ranking is weighted as follows:

  • 30%: health behaviors (tobacco use, diet & exercise, alcohol & drug use, sexual activity);
  • 20%: clinical care (access to care, quality of care);
  • 40%: social and economic factors (education, employment, income, family & social support, community safety); and
  • 10%: the physical environment (air & water quality, housing & transit).”
Counties ranked by health factors.

The RWF’s  methodology obscures a very important distinction: How important are factors based on health behaviors versus factors based on social and economic conditions? Smoking, poor diet, lack of exercise, and unsafe sexual activity are activities over which individuals have considerable control. They also vary by level of income and education. But it’s not the income or education that causes the negative health outcomes, it’s the behavior itself.

The RFW ranking model gives behavioral factors a 30% weight in its health factors ranking, but it’s not clear why the researchers picked that number. Do county-level differences in behavorial factors account for 30% of the variability in health outcomes? Or is the weight assigned arbitrarily?

For example, it is commonly accepted that people who smoke are more likely to suffer health problems. Higher education correlates with higher incomes and less smoking. According to American Health Rankings, in Virginia 31.2% of people with less than a high school education smoke, compared to 6.2% who are college grads. What causes the better health come: the bigger paycheck or the lower rate of smoking?

Another example: The Virginia Mercury notes that Virginia blacks have a higher rate of low-birthweight births than other races/ethnicities: 13% for blacks compared to 7% for whites and Hispanics, and 8% percent for American Indians and Asians. The article doesn’t come right out and say that black babies have lower birthweights because of their mothers’ unequal access to health care, but in the context of the article, that’s the clear implication.

An academic article, “The Risks Associated with Obesity in Pregnancy,” finds a link between a mother’s obesity and low birthweights. “An estimated 11% of all neonatal deaths can be attributed to the consequences of maternal overweight and obesity.” In Virginia, according to The State of Obesity, 41% of blacks were classified as obese in 2017 compared to 28% of whites. 

The aforesaid article notes that “the risks associated with obesity in pregnancy cannot necessarily be influenced by intervention.” Preventive measures to normalize body weight before a woman becomes pregnant are the only way to budge the statistics. In other words, it gets complicated.

One more example: Reckless sexual behavior leading to sexually transmitted diseases falls into numerous categories, according to the Centers for Disease Control and Prevention: exchanging drugs/money for sex, having sex while high/intoxicated, having sex with a person who injects drugs, having sex with anonymous partners, meeting sex partners through the Internet, and having sex with multiple partners. Nationally, the rate of STDs is significantly higher among blacks than whites. (I could not find specific numbers for Virginia.) The CDC argues that part of the racial/ethnic variability may be attributable to differences in access to health care, which allows the diseases to be treated and partners notified, but even that observation comes with a caveat:

Even when health care is readily available to racial and ethnic minority populations, fear and distrust of health care institutions can negatively affect the health care-seeking experience. Social and cultural discrimination, language barriers, provider bias, or the perception that these may exist, likely discourage some people from seeking care.

Yeah, it gets complicated.

Why does this matter? It matters because if you accept the Oppression Narrative, you focus your efforts on changing social and economic variables such as the inequality of education, housing, and income. Conversely, if you believe that negative medical outcomes are due in significant measure to individual choices, you focus on getting people to adopt healthier behaviors. By misdiagnosing the problem and causing a misallocation of resources, the Oppression Narrative hurts those whom its purveyors purport to help.

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15 responses to “Health Care and the Oppression Narrative”

  1. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Another fine article, Jim. You are on a roll.

    The larger narrative is that it’s easy and tempting to blame any bad result on a Oppression Narrative when that bad result is caused of the complainants own failed policies, activities, and ideologies that for generations leave in the wake folks who:

    1/ have not gotten married,
    2/ didn’t go to school to learn, so didn’t learn,
    3/ have fathered several children he hardly knows or not at all, or have birthed several or many children who live alone with her, and who were fathered by several different men long gone,
    4/ have a constant stream of lovers who abuse her and her children,
    5/ never go to church with their children or otherwise,
    6/ live alone and isolated in a crime and drug infested communities,
    7/ are addicted to drugs and/or alcohol,
    9/ are unemployable, refuse to work, or can’t keep a job, and
    10/ who themselves grew up in a broken community of failed relationships and toxic culture quite similar to the broken place they live in now.

    Such folks surely grew up as the children of an Oppressive Narrative. The question is who are the people who chronic refuse to fix that toxic culture that oppresses and destroys its own people and their children?

  2. vaconsumeradvocate Avatar

    There is also research that shows that the food choices/ food behavior of people is closely related to social and economic status. Often fresh vegetables and fruits are not available in lower income communities – and people may not have transportation – or time around working multiple jobs – to shop elsewhere.

    Certainly, behavior is important but the research does not show that it alone can make the difference in health outcomes. If the behavior change is to work, the healthy food must be available and affordable. Thus, I would classify a focus on behavior only as an Unfair and Oppressive Narrative that would lead to misallocation of resources. A better option would be addressing the complicated and intertwined causes together instead of trying to make just one or two factors “the” solution.

  3. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Let’s follow that line of thinking. For example:

    People who don’t go to church regularly for more prone to ill health and earlier death than those who do.

    People who don’t get and stay married are more prone to ill health and earlier death than those who do.

    People, particularly middle aged men, who are unemployed, for whatever reason, for more prone to ill health and earlier death than those who are.

    People who are married and have children are more prone to good health and longer life than those who do not.

    People who are deeply engaged in their communities, and its activities, are more prone to good health and longer life than those who do not.

    People who went to college are more prone to good health and longer life than those who did not.

    People who live chronically with financial, marital, or other social stress are more prone to poor health and earlier death than those who do not.

    Any society that discourages, prevents or demeans these beneficial habits, and/or celebrates, promotes or encourages these other harmful habits, is quite literally harming the health of citizens, and indeed often is killing its citizens or driving them to an earlier death. Hence, for example, the great spike of suicides in America.

    Another words, if you want to open your eyes to see, here here you will find the real Oppression Narrative going on in America.

    1. Reed Fawell 3rd Avatar
      Reed Fawell 3rd

      Here lies the real base reasons why American society, its culture, and increasingly most of its communities, today are falling apart.

      Race has nothing to do with this massive failure, although the disadvantaged (no matter their ethic makeup) were hit first and hardest and now what hit them earlier is spreading to all but the affluent within our society, say the top 10%.

      Identity politics is the scapegoat, the weapon, those seeking to take advantage of this massive failure of leadership grab now. The politicians, academics, crony capitalists, top 1o% hide behind.

  4. LarrytheG Avatar

    Access to health care professionals is how people get that lifestyle advice as well as treatment and drug prescriptions to maintain cadio health, obesity and diabetes, etc.

    It works that way – for rich or poor, urban or rural. Health issues for many have nothing to do with lifestyle decisions. Some are genetic, others are age, some are due to occupational injuries. It’s the full range just like you’d see in an urban area with a lot better access to health care.

    What’s the answer to these folks needs? Touch luck – too bad you live near people who make bad health care decisions?

    1. In Larry World, the only people responsible for their actions are Donald Trump and White Supremacists.

      1. Reed Fawell 3rd Avatar
        Reed Fawell 3rd

        Ever more folks around us everyday painfully remind us how much we all miss the serious study of, and engagement in, the humanities, whether that learning be at a great or middling university, or at home around the hearth or dinner table.

        We all are human after all, and nothing more or less.

  5. Steve Haner Avatar
    Steve Haner

    Larry, if people saw their doc three times a month, most still wouldn’t take the lifestyle advice on smoking, drinking, screwing around and over eating until the chest pains started or Type II diabetes was noted. Even then….. And the obesity epidemic is only marginally related to income, as plenty of people with decent incomes are grossly overweight. More all the time. Entire massive business complexes exist to create the motive and opportunity to consume mass quantities of horrible, horrible poisons. Other massive business complexes exist to put us in our butts on some soft seating, binge watching drivel or staring at a small screen. People make bad choices, and an army of others exists to herd them in that direction.

    We don’t actually care about health in this country. The steps we would take if we did are easy to list. They’d cost politicians the next election, but they are obvious.

    No question, being rich or having a great health plan means you will get better treatment once you have the Type II or the heart condition or HIV, but prevention is largely in our own hands.

    1. LarrytheG Avatar

      I think the main thing I was pointing out was that even if there are higher RATES of obesity or smoking, diabetes in some geography, there are ALSO lots of other folks who have normal habits who need access to health care and the idea that those underserved areas “deserve” to be underserved because “they” don’t take care of themselves is just ignorant lunacy and one has to wonder how folks come up with that kind of wacka-doodle thinking in the first place.

      But I actually think people DO care about health care in this country and we see results at elections including in Virginia.

      But its’ the COST of health care that is the problem – in this country.

      We are the most expensive country in the world for health care – and at the same time we are the worst among developed countries for life expectancy and infant deaths and it’s no coincidence.

      We CAN cover the poor and people in rural America cost-effectively with BASIC health care.

      That’s an essential issue in the debate. Having the govt involved in BASIC health care is NOT having the govt in charge of all of it. All the other developed countries have the govt involved in BASIC health care but they all allow anyone to buy more and better if they can afford it and want it.

      In other words – they keep everyone alive longer by making sure all have access to basic health care. Others who have more money can buy a better quality of life and do.

      We’re so confused and conflicted in this country over this issue and no shortage of just plain wacka-doodle concepts in response to it – like blaming EVERYONE in a geographic area because SOME of them – more than average have bad lifestyles and because of that – everyone who lives in that area “deserves” inferior access to healthcare.

      That’s what passes for “debate” about health care these days.

      1. “The idea that those underserved areas “deserve” to be underserved because “they” don’t take care of themselves…”

        Yes, that idea is lunacy. And I don’t know of anyone who would say such a thing. Total straw man.

        1. Reed Fawell 3rd Avatar
          Reed Fawell 3rd

          In short form, I want to tie in Steve’s and Jim’s above comments with my own above comments, try to show how the all these comments mesh and work together.

          One should never count on the kindness of strangers.

          Similarly, one should never count on the competence and caring of strangers. Indeed, in all matters large and small, one should be wary of strangers. There is a sensible balance here, but its most always best with strangers to go short on trust and long on verify, until trust is verified.

          We all know these rules instinctively. So, living one’s life amid strangers is inherently stressful, harmful and dangerous. Hence now, more and more, we are able to see why our culture, our communities and our health is falling apart for ever more Americans as they increasingly become atomized individuals, strangers in the own land.

          The internet feeds these trends, as do many other false realities that are now flooding our post modern world. Thus there is a growing need of ever more American to reconnect with their real world, rebuild their lost networks and relationships with real living people in their homes, communities, and at work. Only by actively meeting and engaging with real people, building trust among as many people and factions and institutions, can we as human beings learn, grow, thrive.

  6. djrippert Avatar

    “More than 20 percent of Virginia’s black, American Indian and Hispanic populations report poor or fair health, compared to 14 percent of the state’s white residents. …”

    Oh, those pesky Asian-Americans … using their superpowers to become invisible to liberal eyes. I see the article’s author somehow managed to take note of Virginia’s massive American Indian population while omitting Asian-Americans. Of course, if Asian-Americans have health outcomes equal to or better than whites … well, there goes the liberal narrative of white privilege.

    Since the article’s author is another quantitatively challenged William & Mary graduate, let me help:

    Virginia population (2018 est):

    Non-hispanic white …. 61.9%
    African American ……..19.8%
    Hispanic (of any race) ..9.4%
    Asian ………………………..6.8%
    American Indian ………..0.5%

    1. TooManyTaxes Avatar

      Maybe the Foundation and the media have made Asian Americans honorary white people. Somehow I don’t think my kids, who are Korean, would like that. Trump may be disgusting but the left (including most Democrats, academia and the media) are just intellectually dishonest.

  7. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    This more recent commentary above recalls Jim’s article found at:

    See there how the Washington Post put inordinate blame for recent drop and lag in black home ownership on guess who and what: Donald Trump, White racism, and GOP.

    In fact the primary culprit behind this perennial problem has long been the financial and social collapse of large segments of black community after LBJ Great Society programs initiated in 1960s. And how those long gestating and festering problems were most recently were compounded by the sub-prime mortgage debacle created originally during the early Clinton Administration then later turbo charged by the Community Reinvestment Act (CRA) of 1977. This irresponsible policy and directive was driven by Rep. Barney Frank and allies that, in practical affect, after thoroughly corrupting the Fannie Mae mortgage loan underwriting process, then pushed on those toxic loans on unsuspecting and financially disadvantaged borrowers in urban cities like addictive drugs.

    This 10 years later blew up the US economy into the Great Recession. The event triggered foreclosures and bankruptcies on black owners that stripped record amounts of wealth and savings out of the black communities across the nation, from which they have yet to recover.

  8. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Given today’s obsession with race and the oppression narrative, I recently came across a 2018 Pew research study that provides some clarity on many claims and myths within the oppression narrative drumbeat. It touches many subjects discussed earlier.

    As of 2016:

    Asians within the top 10% of income distribution earned 10.7 times as much income as Asians within the lower 10% of income distribution, going from going from 6.1 times in 2007 to 10.7 times in 2016.

    Blacks within the top 10% of income distribution earned 9.8 times as much income as Blacks within the lower 10% of income distribution, going from 9.1 times in 1970 to 9.8 in 2016.

    Whites within the top 10% of income distribution earned 7.8 times as much income as Whites within the lower 10% of income distribution, going from 6.3 times in 1970 to 7.8 times in 2016.

    So between 1970 and 2016 income inequality between richest and poorest Asian’s nearly doubled. Thus Asians displaced blacks as most economically divided race in America, while the economic gap between all Americans over this period increased on average 27%. The richest 10% had 6.9 times more income that the lowest 10% in 1970. By 2016, that gap had widened to 8.7 times more income.

    But the income of the lowest income Asians stagnated at 11% between 1970 and 2017, while the higher income Asians nearly doubled their income, and middle income Asians rose by 54%. Meanwhile white income in top 10% rose 80%, top tier black income rose 79%, and Hispanic to tier income rose 36%. Meawhile, lower income whites, blacks, and Hispanics kept pace with middle income peers, but all slipped relative to higher income Americans of all races.

    Importantly, lower and middle income blacks narrowed the income gap with their white cohorts during this period, gaining more income increases percentage wise than whites within same income group. Hispanics saw lower increases than both whites and blacks within these cohorts.

    When all groups are combined the top 10% of Americans are up 73%, the median income wage earners are up 44%, the lowest 10% up 36%.

    But for the top 10% of Blacks income is up 79%, Black median income is up 66%, and for lowest 10% income of black it is up 67%. This compares to 80%, 52%, and 45% for white cohorts. So blacks are seeing gains.

    Income growth slowed for all races between the year 2000 and 2016, but more so for blacks, likely for the reasons mentioned in my comment above. In any case, there is a great deal to ponder and learn from in this report.

    This is only a brief sampling. It is found at:

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