MPH 504 Week 6 Health Equity Analysis Example

Health Equity Analysis: Tuberculosis Among Residents Born Outside the United States in Alder County, and Which Part of the Gap Is Unjust

Student Name

Chamberlain University

MPH 504: Cultural Competency and Global Public Health

Instructor Name

Month Day, Year

Health Equity Analysis: Tuberculosis Among Residents Born Outside the United States in Alder County, and Which Part of the Gap Is Unjust

The Gap

Alder County, the composite setting used throughout this course, counted 64 TB cases in 2025. Of these, 52 were in residents born abroad, who make up about 230,000 of the county's population, and 12 among the roughly 670,000 residents born in the country. The rate among residents born abroad was about 22.6 per 100,000, against 1.8 among U.S.-born residents, a ratio of about 12 to 1. Nationally the gap is wider still. People born abroad accounted for about three of every four cases reported in 2023, and their rate, 15.0 per 100,000, stood almost 19 times above the 0.8 seen in people born in the country (Williams et al., 2024). The county's figures are composite, built to reflect that national pattern at local scale.

Disparity or Inequity?

Two terms need to be kept apart. Any measured difference in health between groups counts as a disparity; only some disparities are inequities. Whitehead (1992) described inequities as health differences that could be prevented, need not exist and offend a common sense of fairness, and Braveman (2006) added that health disparities of concern are those that track social disadvantage, so that the groups already worse off bear more of the burden. The question for this analysis is therefore not whether the gap exists but which parts of it meet that standard.

The Part That Is Not Avoidable Locally

Most TB disease among people born abroad in the United States results from infection acquired years earlier in a country with high TB incidence, which later reactivates. About 85% of U.S. cases are attributed to reactivation of latent infection rather than recent transmission (Williams et al., 2024). The county cannot change where its residents grew up or the TB burden of the Philippines, Mexico, Vietnam or India. That part of the gap is a disparity rooted in global inequities, but it is not one the county health department could have avoided.

The Part That Is Avoidable and Unfair

What happens after arrival is different. Latent infection is detectable through an interferon-gamma release assay and treatable with a short course of medicine, which prevents most progression to disease. Screening for latent infection in adults at increased risk carries a federal task force recommendation (US Preventive Services Task Force, 2023), and the risk groups it names include people born in, or who formerly lived in, countries where TB is common. If residents born abroad are less able to get tested and treated than the evidence supports, then some of the disease that follows is avoidable, and because that shortfall falls on a group that already faces disadvantage, it is unfair.

The county's own data suggest this is happening. Among 412 non-U.S.-born adults referred to the TB clinic with latent infection in 2024, 63% started treatment and 51% completed it. Completion was 64% among insured patients and 38% among the uninsured. Among patients whose preferred language was not English, 44% completed treatment, against 57% among those who preferred English.

Table 1

Latent TB Treatment Start and Completion Among Non-U.S.-Born Adults Referred to the Alder County TB Clinic

Note. Note. Composite figures from a county clinic record review.

Why the Avoidable Gap Exists

Behavior plays a part, since people choose whether to start and finish treatment, but those choices are made under conditions that the analysis has to name. Four conditions stand out. First, cost: clinic visits and drugs are free at the county clinic, but the blood test for screening in primary care is often billed, so uninsured residents may never be referred at all, and the 207 uninsured patients in the table are the ones who reached us. Second, time: the clinic keeps weekday daytime hours only, closing at 4:30, and many patients work hourly jobs in care homes, warehouses and restaurants without paid leave. Third, language: interpreters are offered by English ability, not preference, so some patients discuss medicines in a second language. Fourth, fear: some residents worry that using a public clinic could affect their immigration status, a concern that persists in the community even where it has no legal basis.

Each condition is avoidable and each is shaped by decisions of the health system or the county, which makes the resulting gap an inequity under both definitions (Braveman, 2006; Whitehead, 1992).

What Narrowing the Gap Would Mean

Narrowing an inequity means changing the conditions that produce it and measuring whether the gap shrinks, not only whether the average improves. The county could pursue four actions: offer evening and Saturday clinic hours twice a month; pay for screening blood tests ordered by community health centers for adults born in high-incidence countries; offer interpreters by preferred language; and switch the first-line offer to one of the rifamycin courses, so treatment takes three or four months rather than nine. A realistic target would be to raise completion among uninsured patients from 38% to 55% within two years, while overall completion rises from 51% to 60%, so that the gap between insured and uninsured patients narrows from 26 points to about 10.

Limits of This Analysis

The county data have three weaknesses that the conclusions must respect. First, they describe only people who reached the clinic, so the most excluded residents, those never tested, are missing, and the true gap is probably larger than the table shows. Second, insurance status and language preference overlap, since many uninsured patients also prefer a language other than English, and the review did not separate their effects. Third, the figures cover one year, and small groups can move several points from chance alone. A fuller analysis would link clinic records to community health center referrals, to estimate how many eligible residents are never referred, and would examine completion by both insurance and language together. None of these limits changes the main conclusion, that part of the gap is avoidable, but they do mean the size of the avoidable part is uncertain.

How Progress Would Be Judged

The county should report completion by insurance status and language every year, alongside the overall figure. If the overall rate rises but the gap stays the same, the inequity has not narrowed, even though the program has improved. The longer-term measure is TB disease among residents born abroad, which would fall slowly, over years, as fewer latent infections progress.

References

Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167-194. https://doi.org/10.1146/annurev.publhealth.27.021405.102103

US Preventive Services Task Force. (2023). Screening for latent tuberculosis infection in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(17), 1487-1494. https://doi.org/10.1001/jama.2023.4899

Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22(3), 429-445. https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN

Williams, P. M., Pratt, R. H., Walker, W. L., Price, S. F., Stewart, R. J., & Feng, P. I. (2024). Tuberculosis: United States, 2023. MMWR Morbidity and Mortality Weekly Report, 73(12), 265-270. https://doi.org/10.15585/mmwr.mm7312a4