Yukiko Asada, Ph.D.
Associate Professor, Department of Community Health and Epidemiology, Faculty of Medicine
Nova Scotia, Canada
A Lesson from Alice and the Cheshire Cat in Health Disparities Wonderland
“Would you tell me, please, which way I ought to go from here?”
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where—” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“—so long as I get somewhere,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”
(Alice’s Adventure in Wonderland1)
Expressing truth about life, this conversation between Alice and the Cheshire Cat is beloved and used in many contexts. Its profound power as a metaphor can also be applied to the science of measurement of health disparities. In Health Disparities Wonderland, Alice might ask, “Would you tell me, please, which way I ought to go from here to put an end to health disparities?” “That depends a good deal on what you mean by health disparities and how you measure and understand them,” would reply the Cat.
In “Harmonizing health disparities measurement” in the special issue of American Journal of Public Health,2 we argued for the science of measurement of health disparities. We believed by now few health disparities researchers and policy-makers would actually answer as Alice would, “I don’t much care about measurement.” But it is not enough for each of us to care. In the article, we urged all of us in the field of health disparities to engage in a community-wide consensus building for harmonization in measurement practice.
One area we highlighted in need of harmonization is health disparity outcome indicators. Health disparities researchers have many indicators to choose from. Advances in medicine and epidemiology have generated numerous indicators of health outcomes beyond mortality, including those related to disease incidence, prevalence, and health status. The large number of health outcome measures in health research generally has led to a situation sometimes called “indicator chaos.”3 For health disparities researchers, the volume of health indicators necessitates separate, focused analysis to ascertain key patterns and trends of health disparities (e.g., Healthy People 2010 with more than 1, 300 indicators4 and 2016 National Healthcare Quality and Disparities Report with 189 indicators5). Only recently has there been guidance on what constitutes an appropriate “health disparity outcome,” and that guidance is not consistently applied.6-8 What we need now is a community-wide consensus building on identifying common health disparity outcome indicators, a relatively small number of indicators of health outcomes consistently measured over multiple years and across multiple studies.
Back to Health Disparities Wonderland, we do not believe Alice would get to where she wants to go even if she walked long enough as the Cat suggested. To put an end to health disparities, if we were the Cat, we would advise Alice to work with others to map and prioritize the current potpourri of measurement practice.
- Carroll L. Alice’s Adventures in Wonderland. Penguin Group; 1998. p. 56. (Original work published 1865).
- Duran D, Asada Y, Millum J, Gezmu M. Harmonizing health disparities measurement. American Journal of Public Health 2019; 109: S25-S27.
- Saskatchewan Health Quality Council. Think Big, Start Small, Act Now: Tackling Indicator Chaos. A Report on a National Summit. Saskatoon, SK: Saskatchewan Health Quality Council; 2011.
- U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. About Healthy People. https://www.healthypeople.gov/2020/About-Healthy-People. Accessed August 7, 2019.
- Agency for Healthcare Research and Quality. 2016 National Healthcare Quality and Disparities Report. Rockville, MD; 2017. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr16/index.html. Accessed August 7, 2019.
- Pérez-Stable EJ. NIMHD vision and agenda. https://www.nimhd.nih.gov/about/legislative-info/clips/nimhd-vision.html. Accessed August 7, 2019.
- National Institute on Minority Health and Health Disparities. NIMHD research framework. https://nimhd.nih.gov/about/overview/research-framework/nimhd-framework.html. Accessed August 7, 2019.
- Thomson GE, Mitchell F, Williams MB, eds. Examining the Health Disparities Research Plan of the National Institutes of Health. Unfinished Business. Washington, DC: National Academies Press; 2006.