The Poor State of America’s Health: Population Health Ethics

Despite spending more on healthcare than any other nation, Americans live shorter sicker lives than their counterparts in other rich and some middle-income countries. The “US health disadvantage” is explained primarily but not completely by the poor health and truncated life spans of America’s poor and low income populations. Contributing, too, are poor levels of health among America’s middle- and upper-classes, who fare worse than their counterparts in other rich nations. Within the U.S., people experience vastly different health and longevity outcomes. Numerous national reports have documented the poor state of America’s health and laid a foundation for action.

Some two decades ago, U.S. bioethics increasingly began to address questions raised by stark differences in health associated with social class, race and ethnicity, geography, and gender. Which health inequalities constitute health inequities? What role does health play in those judgments? How should we think about responsibility for health? Is health a societal, individual, or shared responsibility? How can we address inequities without marginalizing communities burdened by poor health? These are just a few of the central questions of population health ethics.

Addressing Social Determinants of Health

These social conditions embody resources and risks that work through complex psychological and physiological pathways to produce profoundly different health and longevity outcomes. Healthcare matters to human health but far less than most Americans understand. The US County Health Rankings and Roadmaps Project, funded by the Robert Wood Johnson Foundation, estimates that the contribution of clinical services to health outcomes is 20% (Figure 2).

Ethical analyses of such questions reach far beyond medical services and healthcare to address the primary drivers of health inequalities—the “social determinants” of health. Social determinants refer to the social conditions in which people grow up, live, work, play, and age (Figure 1).

Population Health Ethics Programming

The Center’s John B. Francis Chair, Erika Blacksher, PhD, appointed on September 1, 2020, has been working on issues in population health ethics for two decades. Her current research focuses on questions of responsibility and justice raised by worsening white mortality trends, so called “deaths of despair,” and related roles of early life adversity, socioeconomic deprivation, and whiteness. Her work has also addressed debates over the ethics of wellness programs and stigmatization as tools of disease prevention and health promotion. She also explores the vital role of participatory engagement as a facet of policies and programs that aim to promote social and health equity.

Her familiarity and respect for the Center’s community-based engagement model and participatory research efforts comes from her working at the Center early in her career. Dr. Blacksher’s research in community-based deliberations by convening diverse communities in informed discussions about health disparities in search of priorities and solutions will continue as she rejoins her colleagues at the Center. She publishes and speaks frequently on these issues.


S.H. Woolf, A. Laudan Aron. US Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press 2013.
US County Rankings and Roadmaps. Measures and Data Sources. Available at:
https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources

Current Projects

The Center’s fourth John B. Francis Chair, Erika Blacksher, PhD, appointed September 1, 2020, brings a decade of scholarship and practical experience in democratic deliberation to the Center and Kansas City.

Since joining the Center,

  • Dr. Blacksher continues as a consultant to the NIH-funded Center for the Ethics of Indigenous Genomic Research (CEIGR) at the University of Oklahoma, collaborating with CEIGR and tribal leadership to design and implement face-to-face and online deliberations about genomic research, data governance, and biobanking for tribal communities.

  • During Spring and Summer 2021, Dr. Blacksher served on a National Academy of Science, Engineering and Medicine (NASEM) committee to plan a workshop held on June 14-15, Civic Engagement and Civic Infrastructure to Advance Health Equity.” With some 500 people participating, the workshop explored the relationships between civic and political engagement and health. Dr. Blacksher worked with her colleagues to design the workshop’s concluding activity, a “mini-deliberation” in which a subset of participants weighed in on the question: Which civic infrastructure investments are most important to advance health equity.” 
    Click here for NASEM website.

  • Dr. Blacksher has given several talks this Spring on democratic deliberation, for example, speaking about the imperative of meaningful public participation in pandemic planning and response for the National Hispanic Council on Aging, and about deliberative methodology to the Stakeholder Engagement Workgroup of the NIH-funded Clinical Sequencing and Evidence Generating Research Consortium about using democratic deliberative engagement for dissemination planning.

  • During Fall 2020 and Winter 2021, Dr. Blacksher was involved in a series of five online public deliberations about the equitable distribution of Covid-19 vaccines—a collaboration between the New York Academy of Medicine and the New York City Department of Health and Mental Hygiene that sought informed input from a cross-section of New Yorkers regarding which types of essential worker occupations should gain priority for vaccination. Dr. Blacksher developed and delivered an expert presentation on various ways to think about distributive fairness.  (more) 

  • On September 1, 2021, the Center was awarded a grant by County Health Rankings & Roadmaps, a program of the University of Wisconsin Population Health Institute. The project, led by Dr. Blacksher, will build a democratic deliberation toolkit for use in creating a circuit of civic learning, dialogue and connection across race, class and geography.  The toolkit will be used to convene racially, socioeconomically and geographically diverse Kansans and Missourians in a bi-state initiative to learn about, discuss and weigh in on population health issues.

ABOUT ERIKA BLACKSHER (see CV)

Dr. Blacksher looks forward to expanding on the Center’s 35-year history of community-engaged bioethics with her expertise in civic engagement and democratic deliberation.

She gained firsthand experience in public participation at the Center for Practical Bioethics between 1998 and 2002, as Deputy Director of an $11 million Robert Wood Johnson Foundation project, Community-State Partnerships to Improve End-of-Life Care. She worked closely with then Center CEO and the project’s director, Myra Christopher, to provide technical assistance to 21 statewide coalitions seeking to build civic and policy environments supportive of good end-of-life care.

In addition to contributions to scholarly discourse on democratic deliberation, Dr. Blacksher has led the design and implementation of democratic deliberations for several NIH-funded studies.

Center for Practical Bioethics

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