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Disparities and Inequalities

Abstract and Keywords

This entry defines the term disparity as measurable differences between groups on a number of indices. The term disparity originated in France in the 16th century and has been used as a barometer of progress in social justice and equality in the United States. When disparity is examined across the U.S. population over a longitudinal period, it is clear that disparities continue to exist and that they distinguish groups by race, income, class, and gender. African American and Native American populations have historically ranked higher in prevalence and incidence than other populations on most indices of disparity. However, the level of adverse health and social conditions has declined for all population groups in the United States. The disparity indices include mortality rates, poor health, disease, absence of health insurance, accidents, and poverty. Max Weber’s theory of community formation is used in this entry to explain the continued presence and distribution of disparities. Other theoretical frameworks are utilized to buttress the major hypothesis by Weber that social ills tend to result from structural faults rather than individual choice. Social workers are seen as being in a position to challenge the structural origins of disparities as part of their professional commitment to social justice.

Keywords: African American, Asian American, cardiovascular disease, community formation, culture, diabetes, disparity, equality, ethnicity, health, health indicator, health indices, health insurance, HIV/AIDS, inequality, involuntary forces, Latino, life expectance, measurable difference, mental health, mortality rates, Native American, non-Hispanic White, Pacific Islander, policy, poverty, race, racial group, reformer, social institution, social justice, structural factors, structural faults, structural inequality, structural origin, survival rate, theory, violence, well-being

Social workers and political reformers have long sought to eliminate disparity between racial and ethnic groups in the United States. To address the challenges posed by the complex manifestations of inequality in America, disparity must be examined from a comprehensive perspective. A comparative examination shows that although tremendous progress has been made in improving the overall health and well-being of all groups, racial and ethnic disparities persist. No single racial or ethnic group in the United States is exempt from the problems of socioeconomic and health disparities. Surprisingly, whereas Black Americans continue to rank first on almost all disparity measures, White Americans frequently rank second.

The Concept of Disparity

The term disparity originated in the 16th century in France and literally refers to measurable differences between two or more objects or people or to an absence of parity or equality (Plepys & Klein, 1995). Disparity has also been used in several different ways in the context of studying and addressing demographic inequities in the United States. The National Cancer Institute defined disparity as “inequalities in health status,” measured in terms of frequency, diagnosis, mortality, and survival rates by race, income, social class, or ethnicity, where these exceed the expected rates for the population as a whole or when groups are compared against the rates found within the Euro-American population (Center to Reduce Cancer Health Disparities, 2003). In his efforts to establish federal policy to reduce health disparities, President Clinton defined such disparities as “differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the United States” (National Institutes of Health, 2002, p. 7). This definition emphasizes the relationship between socioeconomic status and a variety of disparities in addition to health.

Recently, the Institute of Medicine (2002) defined disparity as differences in access as well as actual treatment between populations where there is no medical or patient justification for the difference. This emphasis on equitable access to treatment reflects the Institute of Medicine’s policy proposal for reducing disparity in the prevalence and incidence of health problems. Despite the ubiquitous application of the term disparity in federal and academic reports, there is no universal agreement in the research literature or in the public-policy sector about its operational definition (Atrash & Hunter, 2006; McGuire, Alegria, Cook, Wells, & Zaslavsky, 2006). Here, disparity will be defined simply as measurable differences between groups, thus avoiding limiting assumptions about the source or nature of the problems to be examined. Anderson (2002) defines prevalence as a measure of the number of existing cases or health problems within a specified population, whereas incidence refers to the number of new cases or health problems.

Demographic Data on Disparities

As early as the first U.S. Census in 1790, federal reports chronicled major differences in socioeconomic, political, and health conditions in the population (U.S. Bureau of the Census, 1975). Early reports showed distinct differences between Black and White Americans on a number of social and health indicators (U.S. Department of Commerce, 1975). Although several populations of color have higher than expected frequencies of socioeconomic and health problems, research, policy, and controversy have centered primarily on inveterate comparisons between Blacks and Whites (Atrash & Hunter, 2006; Byrd & Clayton, 2000). Therefore, there is a lack of comparative data about Native Americans, Latino Americans, and Asian Americans for major portions of the 19th and 20th centuries. In addition, the literature effected the creation of a myth that Euro-American populations were significantly healthier than other racial groups. Demographic data reveal that, although over time the overall health, mental health, and socioeconomic status of Americans has improved, the pattern of racial and ethnic rankings on a number of indices has not changed (U.S. Census Bureau, 2007). No single group in the United States is exempt from problems created by socioeconomic and health disparities.

Socioeconomic Disparities

Census data confirm long-standing historical differences in the economic circumstances of families in the United States by race, ethnicity, language, and culture (Bureau of the Census, 1975; Davis & Bent-Goodley, 2004). The most salient differences are in per capita and familial income levels, families living below the poverty level, and the percentage unemployed. Low rankings on these three indices have characterized some populations of color for decades and are linked closely to differences in quality of life, morbidity, and mortality in these populations compared with other Americans.

Per Capita and Median Family Income

Federal reports identify Latino and African American populations as having the lowest per capita income in the United States (U.S. Census Bureau, 2012). However, Taylor and Kalt (2005) argue that Native Americans on reservations have lower per capita incomes but are not included in many federal income studies. In 2009, Latino and African American populations had per capita incomes of $9,000 to $15,000 less than that of Asian and Euro-Americans. A similar difference was noted in 2009 for median family income by race and Hispanic origin (U.S. Census Bureau, 2012).

Poverty

Although there have been significant decreases in the percentage of families below the poverty level, close to 20% of African and Latino American families continue to live below this level (U.S. Census Bureau, 2007). Asian and White families have the lowest rates of family poverty, whereas Native Americans have the highest rate.

Between 2000 and 2009, there has been an increase in the percentage of individuals and families below the poverty level. Close to 23% of African and Latino American families continue to live below this level (U.S. Census Bureau, 2012). Asian and White families have the lowest rates of family poverty. In 2006–2007, among nonelderly individuals, American Indians and Alaska Natives had the highest poverty rate (33% below the federal poverty level) (The Henry J. Kaiser Family Foundation, 2009).

Unemployment

Historically, African Americans have had unemployment rates that are double the rates of Euro-Americans; Latino and Asian populations have rates similar to Euro-Americans (U.S. Census Bureau, 2007). In 2010, African Americans had the highest unemployment rate at 16%, followed by Hispanics at 12.5%, Whites at 8.7%, and Asians at 7.5%. Since 1975, the labor force participation rate for African Americans was the lowest of the major racial and ethnic groups. In 2010, the labor force participation rate for Blacks was the lowest (62.2%) of the four major racial or ethnic groups (Whites 65.1%, Asians 64.7%, and Hispanics 67.5%) (U.S. Department of Labor, 2011).

Health Disparities

Health Insurance

In 2006–2007, Hispanics were the group most likely to be uninsured (35% lacked health insurance) among those who were under age 65, followed by non-Hispanic Blacks at 21%, Asians and Pacific Islanders at 17%, American Indians and Alaska Natives at 16%, and non-Hispanic Whites at 12% (The Henry J. Kaiser Family Foundation, 2009). Of the five populations for which data were available, four had increases between 1990 and 2004 in the percentage of persons without health insurance. Only the African American population saw a decline in the percentage of persons without health insurance (U.S. Census Bureau, 2007).

Life Expectancy

Life expectancy for all groups in the United States has increased (National Center for Health Statistics, 2012). Although their life expectancy remains lower than that of other major population groups, the most significant increase in life expectancy has been for Black males. Black males born in 2009 could expect to live to 71.1 years compared with 64.5 years for those born in 1990. A White American female born in 2009 could expect to live 81.2 years, whereas a White American male could expect to live 76.4 years. African American female life expectancy was 77.6 years, slightly higher than that of Euro-American males. The Census Bureau reported the combined life expectancy of Asian, Native American, and Hispanic populations in 1996 as 76.1 for women and 68.9 for men (National Center for Health Statistics, 1998; U.S. Department of Commerce, 1998).

Causes of Death

Keppel, Pearcy, and Wagener (2002), Plepys and Klein (1995), and the National Center for Health Statistics (2012) examined age-adjusted death rates for selected causes by race and Hispanic origin (see Table 1). Overall, there were major declines in the death rates per 100,000 population in almost all 11 categories and for almost all populations. However, patterns of death-rate change between 1990 and 2008 were different for selected causes by the five racial or ethnic groups. Asians and Hispanics experienced a slight decrease in deaths from chronic lower respiratory diseases, whereas the rates increased for all other groups. Two of the most significant reductions in death rates occurred in the Black population with regard to HIV and homicides (National Center for Health Statistics, 2006).

Table 1 Causes of Death by Race and Hispanic Origin, 1990 and 2008 (Age-Adjusted Death Rates per 100,000 Population)

1990

2008

Black or African American

American Indian or Alaska native

Asian or Pacific Islander

Hispanic or Latino

White, not Hispanic or Latino

Black or African American

American Indian or Alaska native

Asian or Pacific Islander

Hispanic or Latino

White, not Hispanic or Latino

Diseases of the heart

391.5

200.6

181.7

217.1

319.7

238.6

119.8

100.5

126.3

188.0

Cerebrovascular disease

91.6

40.7

56.9

45.2

63.5

57.4

24.5

33.0

30.9

39.5

Malignant neoplasms

279.5

121.8

134.2

136.8

215.4

209.1

119.6

106.5

114.6

179.4

Chronic lower respiratory diseases

28.1

25.4

19.4

19.3

39.2

30.4

29.3

14.1

18.3

48.7

Influenza and pneumonia

39.4

36.1

31.4

29.7

36.5

18.9

17.2

14.3

14.0

16.9

Chronic liver Disease and cirrhosis

16.5

24.1

5.2

18.3

9.9

7.0

25.7

3.4

13.7

9.1

Diabetes mellitus

40.5

34.1

14.6

28.2

18.3

40.5

34.5

16.0

27.7

19.1

HIV

26.7

1.8

2.2

16.3

7.4

15.3

2.1

0.6

3.6

1.4

Unintentional injuries

43.8

62.6

23.9

34.6

35.0

33.3

53.5

15.4

27.9

42.6

Suicide

7.1

11.7

6.7

7.8

13.8

5.3

11.7

5.8

5.6

14.1

Homicide

36.3

10.4

5.0

16.2

4.0

19.5

7.1

2.3

6.6

2.8

Note: Adapted from “Health, United States, 2011: With special feature on socioeconomic status and health” by National Center for Health Statistics, 2012. Copyright 2012 by the Centers for Disease Control and Prevention, National Center for Health Statistics; “Trends in racial and ethnic-specific rates for the health status indicators: United States. 1990–98” by K. G. Keppel, J. N. Pearcy, & D. K. Wagener, 2002, Healthy people 2000 statistical notes (Rep. No. 23). Copyright 2002 by the Centers for Disease Control and Prevention, National Center for Health Statistics; and “Health status indicators: Differentials by race and Hispanic origin” by C. Plepys and R. Klein, 1995, Healthy people 2000 statistical notes (Rep. No. 10). Copyright 1995 by the Centers for Disease Control and Prevention, National Center for Health Statistics.

Groups

Infant and Maternal Mortality

Infant and maternal mortality rates among racial and ethnic minority populations remained considerably above the national mean throughout the 20th century. From 1900 to 2000, infant and maternal mortality rates for all groups of Americans declined. When infant mortality rates are compared between 1990 and 2003, the ranking by race and Hispanic origin has not changed (Census Bureau/National Center for Health Statistics, 2001). African Americans ranked first, with Native Americans second. The lowest infant mortality rates were found in Asian and Pacific Islander populations. There were minimal differences between Hispanic and Euro-American rates, which are close to one half the rates of African Americans and Native Americans. In 2007, similar patterns of infant mortality rates persisted. Non-Hispanic Blacks had the highest infant mortality (13.3%), followed by American Indians or Alaska Natives (9.2%), whereas Puerto Ricans had a higher rate of infant mortality than did non-Hispanic Whites, Mexicans, Cubans, Asians, or Pacific Islanders and Central and South Americans had lower infant mortality rates (MacDorman & Mathews, 2011).

Deaths From Violence

Marked differences exist in homicides by race and Hispanic origin. By 2008, the rates for homicides per 100,000 for males and females in every group had declined from the rates recorded in 1990. The homicide rate for African Americans in 1990 was 36 per 100,000 population, whereas the next highest rate was 16 per 100,000 for the Latino population. Rates were 10 per 100,000 for Native Americans and 5 per 100,000 for Asian Americans. The lowest homicide rate (4 per 100,000) was for the White population in 1990. By 2008, deaths from homicides had declined for all populations. However, African Americans continued to rank first, at 20 deaths per 100,000 population, followed by Native Americans. Homicide rates for Asian Americans (2.3 per 100,000) were the lowest in 2008; rates for the White population were slightly higher at 2.8 per 100,000 (Keppel et al., 2002; National Center for Health Statistics, 2012; Pearcy & Keppel, 2002; Plepys & Klein, 1995).

Cardiovascular Disease and Stroke

In the United States, death rates per 100,000 population from cardiovascular disease are highest among African American males and lowest among Asian and Pacific Islander American women (295.6 and 81.7, respectively, in 2008). The second highest rate (235.9 in 2008) was among non-Hispanic White males. Rates for African American women were 197.5 per 100,000 in 2008 (National Center for Health Statistics, 2012). Rates for all groups were substantially higher in 1990, with African American male rates close to 500 and White American males close to 415 per 100,000 population. Although rates declined for all American populations by 2008, there was no change in the rank order of frequency by racial group or ethnicity. African Americans (male and female) and White Americans (male and female) had the highest rates throughout the 20th century.

Diabetes

Six million Americans (8.3% of the U.S. population) have diabetes, and an estimated seven million have the disease but have not been diagnosed (Centers for Disease Control and Prevention, 2011). Rates are highest (27%) in the population over age 65 and among men (11.8%) compared with women (10.8%) (Centers for Disease Control and Prevention). A greater percentage (16.3%) of Native Americans age 18 and over have diabetes, and African Americans and Latino Americans have similar prevalence rates (12.9 and 13.2%, respectively). White populations had the lowest (7.6%) prevalence rate (Schiller, Lucas, Ward, & Peregoy, 2012). However, the incidence rate (26) per 100,000 white youths below age 20 was the highest in the United States. The lowest incidence rate (16.7) was found in Asian or Pacific Islander youth (Brown, 2007). Death rates from diabetes increased for all populations from 1990 to 2004. Rates for African Americans increased from 40 to 48 per 100,000 population, whereas rates for Native Americans increased from 34 to 39. Death rates from diabetes in Latino populations increased from 28 to 32 and from 18 to 21 and 14 to 17 per 100,000 for Euro-Americans and Asian Americans, respectively, from 1990 to 2004 (National Center for Health Statistics, 2006). However, death rates from diabetes declined across all racial groups from 2005 to 2008 (National Center for Health Statistics, 2012).

HIV Infections/AIDS

In the early 1990s, HIV/AIDS infection rates for African American populations were close to 155 per 100,000, far exceeding the rates for all other U.S. populations. Death rates for HIV/AIDS varied considerably in 1990 from 27 per 100,000 in African American populations to 1.8 for Native Americans. By 2008, the rate of deaths per 100,000 had declined in four of the five population groups. In 2008, the rate for Native Americans had increased to 2.1 from 1.8 per 100,000 population in 1990. The rate for African American populations remained the highest, at 15.3 per 100,000, although this rate represented a significant decline from the 1990s (Keppel et al., 2002; National Center for Health Statistics, 2012; Plepys & Klein, 1995).

Deaths From Influenza and Pneumonia

Deaths for all American populations from influenza and pneumonia declined substantially from 1990 to 2008 (National Center for Health Statistics, 2012). Rates for Native American populations declined from 36 to 17 per 100,000, whereas the rates for Asian populations declined from 31 to 14 during this period. Rates per 100,000 for Hispanic and Euro-Americans declined from 30 and 37 to 14 and 17, respectively. African Americans had the highest death rates per 100,000 from influenza and pneumonia in 1990 (39) as well as in 2008 (19).

Changes in Rankings

From 1990 to 2008, mortality rates ranked by race and Hispanic origin showed minimal changes (Table 2). Death rates overall and within categories were highest for the Black population at the beginning of the 1990s and in 2008. The ranking of African American deaths from suicides declined from fourth to fifth between 1990 and 2008. Of significance, the death rate for American Indians from HIV/AIDS increased in rank from fifth to third for this same period. Rankings for Asian American populations remained the most stable during the 18-year span with the exception of suicide, whereas the ranking for White American death rates from accidents increased from third to second.

Table 2 Changes in Ranking of Mortality by Race, Hispanic Origin, and Year

Causes of mortality

African Americans

American Indians

Asian Americans

Euro-Americans

Latino Americans

(1990)

(2008)

(1990)

(2008)

(1990)

(2008)

(1990)

(2008)

(1990)

(2008)

Heart disease

1

1

4

4

5

5

2

2

3

3

Homicide

1

1

3

2

4

5

5

4

2

3

Suicide

4

5

3

2

4

3

1

1

2

4

Cerebrovascular disease

1

1

5

5

3

3

4

2

2

4

Malignancy

1

1

5

3

3

5

2

2

4

4

Respiratory disease

2

2

3

3

4

5

1

1

5

4

Influenza

1

1

3

2

4

4

2

3

5

5

Liver diseases

3

4

1

1

4

5

5

3

2

2

Diabetes

1

1

2

2

5

5

4

4

3

3

HIV/AIDS

1

1

5

3

4

5

3

4

2

2

Accidents

2

3

1

1

5

5

3

2

3

4

Mental-Health Disparities

A series of studies since the 1960s has consistently reported minimal, if any, differences in the incidence and prevalence of mental illness by race and ethnicity (Fischer, 1969; Neighbors & Lumpkin, 1990; Robins & Regier, 1991). Recent replications of earlier studies by Wang et al. (2005) and Kessler et al. (2005) also support this finding. Wang et al. (2006), however, identified significant differences in service use patterns by race, ethnicity, gender, and income. The Five-Year Strategic Plan of the National Institute of Mental Health focuses on eliminating disparities in service (access, quality, outcomes) by race, color, ethnicity, and culture based on the relative homogeneity in incidence and prevalence of mental disorders. The National Institute of Mental Health has identified constraints in help-seeking, impediments to access, and poorer outcomes by race, ethnicity, and social class as important variables. The focus on service disparities is congruent with the conclusions of the Surgeon General’s report (U.S. Department of Health and Human Services, 2001) and the broad tenets of a report by the Institute of Medicine (2002). Numerous other studies have documented the barriers to and differences in the use of mental-health services by race and ethnicity (Abe-Kim et al., 2007; Alegria et al., 2007; Johnson & Cameron, 2001; López et al., 2004; Neighbors et al., 2007; Spencer & Chen, 2004; Substance Abuse and Mental Health Services Administration, 2012; U.S. Department of Health and Human Services, 2001; Wang et al., 2006).

Theoretical Perspectives

Disparities are complex phenomena and numerous research studies have yet to identify any single explanation of the causes of these disparities that have been accepted in the scientific community or by public policy makers. Although the causes of disparities are difficult to pinpoint, Weber’s theory of community closure (Neuwirth, 1968) provides an alternative meaning and explanation of the existing disparities, which may be useful for social workers seeking to understand and reform structural factors.

Weber’s Theory of Community Closure

Max Weber’s theory of community closure offers a useful explanation of disparity in the United States. Weber proposed that human groups compete with each other for limited resources within the environment. Groups that are able to garner or exercise power and control over limited societal resources survive, thrive, and reduce their risk of adverse circumstances—starvation, disease, sickness, early mortality, or dependence. On the other hand, groups without power and control of available resources have a higher risk of these problems. Weber’s theoretical formulation suggests that basic resources are essential not only to survival, but also to overall life quality and satisfaction. Various studies reinforce the Weberian perspective. Pratto and Sidanius (1999) identified power and dominance by elites as the key factors that contribute to the uneven distribution of opportunity. Conley (1999) concluded that adverse economic circumstances not only affect immediate life chances of families of color, but also have a cumulative adverse effect for generations.

Weber (as cited in Neuwirth, 1968) indicated that the quest for survival and growth propels human groups to act in ways that increase the probability of obtaining a share of scarce resources. Weber describes these actions as competition between groups. Competition between groups requires some differences in identifiable characteristics. Durkheim (1951) proposed that in competition for resources, social status, authority, or power, groups will seize on any personal characteristic, such as height, weight, language, culture, skin color, or clothing, to establish a system of favored in-groups and rejected out-groups, which Weber called negative privileged status groups.

Once groups are formed, they seek to monopolize resources as well as the vital processes used to develop, access, enhance, or protect them for their own group. Weber believed that once group formation took place, powerful groups closed or delimited access to outside groups through a process of community closure. The groups excluded through closure have a higher than average risk of developing social problems based on limited access to the needs-meeting social institutions in their society.

Neuwirth (1968) used Weber’s community formation theory to explain the higher than expected frequency of social ills in African American communities. Neuwirth explained that not only are African American populations provided limited access to social capital, but the power of community closure by the White power structure also limits the ability of outsider groups to form or maintain their own internal closure. Disparities arise from a continuous process of exclusion, delimitation, monopoly of existing resources, and an active process of limiting excluded groups from developing systems, infrastructure, and opportunities within their own communities. In addition to Weber’s conceptualization, Green (2003), Byrd and Clayton (2002), Stone (2006), and Diamond (1997) provide complementary perspectives. Green proposes that health disparities result from an absence of civil rights enforcement. Green argues that the Civil Rights Act of 1964 outlaws disparate treatment that results in limited access to health care, poor quality outcomes, and poor health status. Byrd and Clayton propose that health disparities result from two forces. Continued reliance by populations of color on public sources of health care results in lower quality of health and numerous health problems. In addition, Byrd and Clayton suggest that scientific racism is the key factor that causes and sustains health disparities. Stone proposes that disparities result from major gaps in access to quality medical care. She argues that the gap in access can be measured quantitatively and, if addressed, reduces the extent of disparities. Stone concludes that the essence of the disparities problem is political indifference and public misinformation about the impact of limited access to quality medical care. Diamond theorizes that disparities between groups stem from the interaction of three variables: control of weapons, the spread of disease, and the production of steel. In essence, Diamond believes that the greater the extent of inequality within a society, the greater the chances are that specific groups that lack access to and control of resources will evidence disparate life conditions.

Trends

These data show clearly that long-standing differences in life conditions and mortality exist by race, ethnicity, and culture. Some populations of color (African Americans, Native Americans, and Mexican Americans) have consistently been overrepresented on several indices of disparity; however, the prevalence and incidence patterns by race and ethnicity are uneven. For example, although the leading causes of death for African Americans and Euro-Americans are similar, the rates for African Americans are usually considerable higher. With regard to health and socioeconomic status, African American, Native American, and Latino populations generally rank lower than Asian and Euro-American populations. Although critical differences exist with regard to health and mortality associated with populations of color, lower socioeconomic status seems to be the most important predictor of disparities in the 21st century.

Demographic data show progress in improving Americans’ well-being. Disparities are not confined to populations of color alone, although some (poverty, absence of health insurance, unemployment, and high mortality rates) are disproportionate to African American, Mexican, Puerto Rican, and Native American populations, and pose a great challenge to the field of social work in the 21st century. The United States has reached a point where structural changes are called for to address the problem of disparity. Innovations in social work and modern political and societal sensibilities now make it conceivable that structural shifts can occur because American scholars now have a much more in-depth understanding of the pathways to disparity and the role of the distribution of opportunity and access within our society.

Implications and Roles for Social Work

First, disparities are ubiquitous social phenomena that occur in all populations in the United States, not simply along racial, ethnic, or color lines (Satcher & Pamies, 2006). Actions that focus on only one segment of the population cannot succeed in eradicating problems in the structure of social institutions and policies. Second, the frequency of disparate conditions has declined considerably in all groups since 1990, although the frequency of some conditions such as HIV/AIDS and diabetes continues to increase. Third, although all groups have made progress, African American and Native American populations continue to rank higher on negative indices of health and well-being and lower in income than most other groups. Fourth, White Americans rank second on a number of mortality indices and first in suicides. These four patterns appear consistently across decades with limited variation. Many of the problems seem to be related, but it is not clear why, increasing the difficulty in identifying solutions, treatments, interventions, or prevention.

If one can assume that groups do not willfully choose disparities, then involuntary forces must be causing both the development of these problems and the distributional patterns that have been so consistent over many decades. Disparities occur across racial, cultural, and ethnic lines, but these factors alone should not be viewed as the single causes. Weber’s work (as cited in Neuwirth, 1968) suggests that the underlying causes of many of these problems are in the societal structures where access, policy, resource distribution, values, opportunity, and rights are determined. Weber (as cited in Neuwirth) proposes that barriers placed before a group increase the group and individual member’s risk of harm, lower achievement, and distress. For Weber, the issue is structural inequality that bears heavily and disproportionately on groups that can be identified by some characteristics such as race, culture, language, region of the country, gender, sexual preference, disability status, housing, weight, height, employment status, education, or age. Weber’s theory (as cited in Neuwirth) proposes that discrepancies between needs and opportunities increase the level of risk for disparities in one or more of the categories discussed in this entry.

The social-work profession does not focus as much on individual motivation with respect to meeting or ignoring health-care needs. Rather, reformers have concentrated on the prohibitive cost, lack of accessibility, and culturally incompetent nature of care, which increases the risk of mortality, disability, or severe illness. They have also fought for over 100 years with other reformers in the United States to pass legislation that would provide universal coverage to all citizens regardless of their personal, group, or regional characteristics. Gil’s (1987) work suggests the policies formulated and implemented by the powerful are the source of major social problems. Gil proposes that social workers and other reformers measure their actions by the extent to which change occurs in the distribution of rights, resources, and social status.

The key challenge for social-work reformers in the early 21st century is how to make further progress in reducing problems (consistent disparities in health, employment, income, education, mortality, and incarceration rates) that appear almost intractable, resistant, and embedded in the structure, policies, and essential functions of American society. Social workers can adopt a Weberian approach to the problem of disparities by looking beyond traditional limitations and being open to solutions from unexpected sources. One way in which this can be achieved is by demonstrating the investment value of lessening disparities for the entire population to current fiscally conservative audiences and institutions. In this way, the field of social work can overcome historical limitations and motivate even unlikely parties to work toward change by taking an approach that respectfully appeals to logic, emotions, economic sensibilities, and ethical values.

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