Foreword From Edited Book                    

The publication in 2004 of another book on health and health related issues is both timely and urgently needed to add fresh, invigorating and comprehensive insights to on-going national, regional and local discussions concerning the unequal distribution of "good" health and "desirable" services in America. Eliminating disparities in health care and health status between racial/ethnic groups in the United States have become perhaps the most serious challenge facing the nation. Although various ethnic groups can be singled out for special consideration, no group comes to the national attention more vividly than African Americans who trail their White counterparts on just about all major indicators of morbidity and mortality.

Since the publication of the Secretary’s Task Force Report on the health of Blacks and other minorities over eighteen years ago, which officially brought the issue of ethnic disparities in health to national consciousness, a great deal of activity has occurred to underscore this national problem. For example, in the past few years the US Department of Health and Human Services has introduced major initiatives in the area: 1) including the Healthy People 2010 goal of eliminating health disparities among various segments of the population and 2) activities at the National Institutes of Health (NIH) and The Centers for Disease Control and Prevention (CDC) supporting research to better understand racial/ethnic disparities in health.

Although major progress has been made in reducing morbidity and mortality, as well as increasing the life expectancy among vulnerable and at-risk populations, such as African Americans, the ethnic-divide continues to widen. As a matter of fact, in some cases it has even gotten worse! Because we are essentially dealing with the inherent complexities of human behavior on the micro or individual level, which are inextricably tied to on-going factors and conditions at the macro or societal level, the reasons for the lack of more substantial improvements over the ensuing years are complex.

To suffice, however, it can be reasoned that increased vulnerability to adverse health among African Americans is differentially mediated by various environmental factors and conditions. All of these factors and conditions serve to influence individuals’ personal choices concerning healthy lifestyle choices; availability, accessibility and acceptability of services; and, ultimately, impact negatively on their physiologic functioning, hence the current health disparities dilemma. At the risk of oversimplifying a complex situation, what is desperately needed at the macro level is health care reform to guide the nation’s policies and research agenda. Such reform should also serve to underscore the fact that health care is a right and not a privilege. At the micro level, self-care actions must be fueled by greater feelings of efficacy and empowerment. Such feelings can only be expressed and be sustained by the acquisition of health and lifestyle alteration information and resources, for example, through federal, state and local educational campaigns.

Even with the eventual advent of health care reform, African Americans and their advocates must continue looking to and dealing with various challenges. Some of these challenges are associated with a) attitude and lifestyle modification and b) prevention of disease and disability in the context of an ever-changing, dynamic, unpredictable and, sometimes, "racially unsympathetic" social and political environments. One way to begin, or continue on this difficult journey, is to be more fully aware of the "information puzzle" associated with the variety of conditions that affect the lives and health status of African Americans.

This 2^nd Edition of the Handbook of Black American Health: Policies and Issues Behind Disparities in Health, by Dr. Livingston, expand on the 1^st Edition that was published in 1994. This widely expanded edition, which has twenty new chapters (i.e., from 27 to 47), attests to the comprehensive nature of the text. The additional topical areas (e.g., oral health, physical activity, reproductive health, emergency room medicine, complementary health geographic information systems, human genome, clinical trials) further attest to the wide range of areas that have to be addressed because of their individual and collective contribution to the debate on disparities in health in the 21^st century.

The book is clearly multidisciplinary and its 47 chapters reflect this perspective. The editor, Dr. Livingston, who is a trained medical sociologist and social epidemiologist, was successful in bringing together a team of known experts in their respective areas from a variety of institutions across the country. Where applicable, the common public health theme throughout the book includes the importance of (primary) prevention, the etiology of the problem being addressed, detection and diagnosis of the problem, and the need to successfully intervene. The voluminous information that resonates through all of the chapters, as well as the sequencing of the chapters, is deliberately orchestrated to give the reader the opportunity to contribute valuable information to the race/ethnicity-health disparities relationship.

The perspective of the eclectically trained editor, Dr. Livingston, is reflected in the vast, comprehensive and unique topics covered in the text, which makes it an ideal reference text. The book is particularly unique in that it includes a variety of very current topical areas (e.g., oral health, emergency room medicine, rural America, prisons, human genome, geographic information systems) not previously covered in a single text. The content of the book argues strongly that it will make significant and timely contributions in the increasingly crowded field of health disparities publications. Not to be deterred by the vast array of information, the chapters are sequentially presented under five major sections. Moving from cardiovascular and general conditions through lifestyle and socio-political and structural challenges, the book ends with an examination of ethics, research, technology and social policy issues.

As a former Surgeon General of the United States, I am uniquely aware of the multidisciplinary focus needed to understand, and ultimately successfully resolve, the complex issues that contribute to African Americans trailing their White counterparts on just about all recognizable health status indicators. I am encouraged to see that the chapters included in this book reflect that basic four determinants of health and illness as defined by the Office of the Surgeon, as well as others, i.e., lifestyle, environment, genetics/biology and access to medical care. The ten leading health indicators in Healthy People 2010 further explicate these determinates.

The careful selection of chapters in the book reflects an appreciation by Dr. Livingston of the interaction of all the four determinants of health, as well as a greater appreciation that over fifty percent of health care risks can be explained in terms of lifestyle factors. The data are increasingly suggesting that lifestyle conditions, e.g., stress, exercise, spirituality, nutrition, mental health, pharmacological therapy and reproductive activities may have either a direct or indirect impact on other more physiological health outcomes, e.g., heart disease, cancer, immunological functioning, HIV/AIDS, diabetes. Again, all of these topical areas are represented by chapters in the book. Because the final action resides with individuals, whether to engage in preventive and/or protective health behaviors, they have to become empowered to realize and accept this responsibility for their health. This being the case, a chapter in the book on "Transforming Structural Barriers to Improve the Health of African Americans" addresses this issue quite clearly in discussing how African Americans can become more empowered, in the context of available structural realities (e.g., access and availability of health care) to improve their health.

The second edition of Dr. Livingston’s comprehensive Handbook of Black American Health deserves to be on the bookshelf. For years to come, it will serve as an invaluable resource for policymakers, health care practitioners, teachers, researchers and students, both in the medical and behavioral sciences, who are seriously concerned about understanding and, subsequently, reducing the numerous health disparities between African Americans and their White counterparts. As we move forward as a nation to resolve issues relating to health disparities, whether they be at the societal or individual levels, this book will be an invaluable resource that will assuredly move us in that direction.

David Satcher, M.D., Ph.D. F.A.A.A.P., F.A.C.P.M., F.A.C.P.

Director, National Center for Primary Health Care

Morehouse School of Medicine