In This Issue

This issue of The Milbank Quarterly begins and ends with a focus on disparities in health and health care, a topic of great concern in health policy and research in many countries. The first article, “Summarizing Social Disparities in Health,” by Yukiko Asada, Yoko Yoshida, and Alyce Whipp, describes how disparities associated with multiple attributes such as income, education, sex, and race/ethnicity can be reported. Applying a graphical method developed by statistician Joseph Gastwirth (2007), they present data from the 2009 American Community Survey to show the relative contributions of these variables to the overall health disparity profiles of the U.S. states and the District of Columbia. The health measure they use is functional limitations, but the method can be applied to other health status measures as well. They show that race/ethnicity is the largest contributor to health disparities in thirty-four states and that socioeconomic factors are the major contributor in seven. In the other ten states, the two sets of factors make roughly equal contributions. The authors’ major contribution is in showing how policy-relevant information about multiple sources of disparity can be presented to facilitate comparison and interpretation across reporting units or over time.

The next article in this issue is “Making Sense of ‘Consumer Engagement’ Initiatives to Improve Health and Health Care: A Conceptual Framework to Guide Policy and Practice,” by Jessica Mittler, Grant Martsolf, Shannon Telenko, and Dennis Scanlon. Although the value of getting people more engaged in their health and health care has skeptics as well as advocates, the Patient Protection and Affordable Care Act contains provisions to increase the availability of information and assistance to improve patients’ decision making and to facilitate wellness activities and self-management programs. Mittler and her colleagues participated in evaluating the Robert Wood Johnson Foundation initiative called Aligning Forces for Quality (AF4Q), which sought to improve consumer engagement in sixteen communities across the country. They found that they needed a conceptual framework to help them distinguish among the various interventions being tried in the study communities. Their article presents that framework and the research literature on which it is based.

The authors distinguish between patients and consumers and between “activation” (having the capacity and motivation to act) and “engaged behaviors.” Their ECHC framework (for Engaging Consumers in Health and Health Care in Communities) distinguishes among self-management, health care encounters, shopping, and health behaviors, each of which can involve individuals, groups, and communities. After presenting their framework, the authors apply it to one of the AF4Q initiatives: the Puget Sound Health Alliance in Washington State. They conclude by observing that although evidence is “elusive” regarding effective ways to improve consumer engagement in health and health care, having a conceptual framework for distinguishing among interventions is a step forward.

The next article in this issue is “Health Systems’ ‘Surge Capacity’: State of the Art and Priorities for Future Research,” by Samantha Watson, James Rudge, and Richard Coker. Questions about the ability of health systems to handle rapid increases (“surges”) in the need for services have been raised recently in many places because of catastrophic events and growing concerns about the risk of pandemics. Based on a systematic review of the literature (most of which comes from the United States), the authors report that the development of standardized models, measurements, and metrics for planning purposes has been hampered by data limitations and variations in conceptualization, terminology, and definitions. They propose ways to address these problems to improve future health system planning for, and responses to, disasters and pandemics.

The next article, “Federalizing Medical Campaigns against Alcoholism and Drug Abuse,” by Grischa Metlay, focuses on the history of two key federal agencies created in the 1970s: the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Special Action Office for Drug Abuse Prevention (SAODAP). Metlay explores why the latter obtained more resources than the former, even though there were more alcoholics than drug addicts, alcoholism was less stigmatized, and advocates concerned with alcoholism made stronger lobbying efforts. He concludes that two factors were involved. The first is that alcoholism was framed as a public health issue, whereas drug abuse became part of broader concerns about crime and social decline. The second was that support for alcohol programs was largely located in Congress, while prominent champions for drug abuse funding had important roles within the Nixon administration. Metlay’s analysis is of interest because of recurrent proposals regarding the reorganization of NIAAA and the National Institute on Drug Abuse (NIDA). It also informs the perennial question of whether and how funding levels for programs should relate to the relative magnitude of the problems that those programs address.

That same question is the focus of the next article, “New Evidence on the Allocation of NIH Funds across Diseases,” by Bhaven Sampat, Kristin Buterbaugh, and Marcel Perl. Their analysis links information from the National Institutes of Health’s Research, Condition, and Disease Categorization database regarding funding levels for research related to 107 different diseases to data about the burdens of those diseases as measured by deaths and hospitalizations. They find an overall association between disease burden and NIH funding, although there are differences across institutes. They conclude with observations about different kinds of funding mechanisms and the targeting of research priorities.

At the end of this issue, we return to the topic of health disparities, with four commentaries related to John Frank and Sally Haw’s article “Best Practice Guidelines for Monitoring Socioeconomic Inequalities in Health Status: Lessons from Scotland,” which was published in the Quarterly in December 2011. Frank and Haw (2011) proposed four criteria by which to appraise measures of inequality: completeness and accuracy of reporting, reversibility and sensitivity to intervention, avoidance of reverse causation, and statistical appropriateness. They then applied these criteria to “cutting edge” reports by the Scottish Government on inequality. In this issue, we offer comments about the Frank and Haw article from Gerry McCartney and colleagues, who were responsible for the Scottish reports, and a response from Frank and Haw. These are followed by brief commentaries about the Frank and Haw criteria by Carolyn Clancy and Ernest Moy, who are responsible for the American Agency for Healthcare Research and Quality’s annual reports on health disparities, and by Sam Harper and Nicholas King, who are authors of a 2010 Quarterly article on the values built into disparity measures (Harper et al. 2010).

Bradford H. Gray


Frank, J., and S. Haw. 2011. Best Practice Guidelines for Monitoring Socioeconomic Inequalities in Health Status: Lessons from Scotland. The Milbank Quarterly 89(4):658–93.

Gastwirth, J.L. 2007. A Graphical Summary of Disparities in Health Care and Related Summary Measures. Journal of Statistical Planning and Inference 137(3):1059–65.

Harper, S., N.B. King, S.C. Meersman, M.E. Reichman, N. Breen, and J. Lynch. 2010. Implicit Value Judgments in the Measurement of Health Inequalities. The Milbank Quarterly 88(1):4–29.

Author(s): Bradford H. Gray

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Volume 91, Issue 1 (pages 1–4)
DOI: 10.1111/milq.12000
Published in 2013