COVID-19 and the racial reckoning this country is facing have laid bare in an extremely dramatic way the many inequities in our society. These are “preexisting conditions” of another sort, and they are very longstanding. They include socioeconomic, gender, and racial/ethnic disparities as well as criminal injustice. Although some may view these inequities as the problem of a few, they impact all of us. Nowhere is that more clear than in the realm of health and well-being.
None of us are spared, both directly and indirectly, from a health challenge at some point in our lives. And it is much more the rule than the exception that health inequities reflect systemic issues that few of us can escape. That means we all have a personal stake in addressing them. In addition, all of us benefit when they are eradicated.
Though the quest may be daunting, the benefits which accrue are immense and extend beyond health per se. They may actually prove to be life-saving. The road to health equity, rocky though it may be, must be pursued to maximize our physical and emotional health and well-being and our ability as a society to thrive, not just survive.
What is health equity?
The Centers for Disease Control defines health equity as the opportunity for every person to “attain his or her full potential.” No one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.”
Several factors impact an individual’s health and well-being, including:
- age
- gender
- socioeconomic status
- educational background
- race/ethnicity
- language and culture
- sexual orientation and gender indentity
- disability status
- geographic locale
- systemic racism
Communities of color have been hit hardest by COVID-19 for a number of the reasons which include, but are not limited to, living conditions, health circumstances, and finding themselves in jobs deemed to be essential work and which meant daily potential exposure to the novel coronavirus.
For example, Black and Latinx people are more likely to live in densely populated areas making it harder to social distance. Crowded housing, real estate redlining, and environmental injustice which increases the risk of living under conditions of air pollution and toxic materials like lead paint also put residents at risk for health conditions like asthma and cancer, thereby increasing one’s chance of COVID-19 complications and death.
There are also personal situations like multi-generational households which make it harder to stop the spread and protect older populations.
Work circumstances are also a factor. This includes an individual’s inability to work from home during the lockdown due to essential worker status, no sick leave, and no health insurance.
Many people were not supplied with adequate Personal Protective Equipment (PPE) by their employers. The result? Workers’ health (and that of their families) was put at risk because day-to-day survival depended on their low-wage paycheck.
COVID-19 put health equity in the spotlight in a way that society could no longer look away or “unsee.”
Evidence of health inequities
Health inequities are reflected in differences in longevity; quality of life; rates and severity of disease, disability, and premature death; access to care; and treatment options, both those presented as well as those made available.
Did You Know?
1. Women have worse long-term outcomes as well as increased hospital readmissions following coronary bypass surgery compared to their male counterparts.
2. LGBTQ youth are 2 to 3 times more likely to attempt suicide.
3. Men are more likely to engage in excessive alcohol consumption and smoking.
4. African Americans suffer the highest mortality rate for all cancers combined than any other racial/ethnic group.
5. The rates for the leading causes of death in the U.S. – COVID-19, heart disease, cancer, unintentional injury (including vehicle accidents and opioid overdoses), chronic lower respiratory disease, and store – are higher in rural communities.
6. Asian Americans are 40 percent more likely to be diagnosed with diabetes than non-Hispanic whites.
7. Rates of COVID-19 infections are greater in Latinx communities and those with low household income and lower education levels. Rates of severe complications and death from COVID-19 are greater in Black, Latinx, Indigenous peoples, and other communities of color.
What’s the difference between health equity and equality?
Achieving health equity means better health and healthcare for everyone.
“Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly.”
~ Martin Luther King, Jr.
It requires systemic issues to be addressed, a greater understanding of the factors that contribute to health and well-being, improved communication and engagement, and the delivery of holistic, integrated, patient-centric care.
A system that drives and supports health equity positively impacts not just a single individual or subsegment of the population but the health and well-being of all of us, both now and for generations to come.
The Robert Wood Johnson Foundation tells us equity is not the same as equality. As seen in the infographic above, equality looks different than equity. Equality means everyone gets exactly the same thing. Equity means everyone gets what they need to achieve an equal opportunity at optimal health and well-being.
For example, those with worse health and fewer resources due to a rural location or lower socioeconomic status driven by racism or sexism need more efforts expended to improve and maximize positive health outcomes.
Achieving health equity requires us to address issues related to:
- health (il)literacy
- health disparities
- social determinants of health (SDOH) and
- cultural sensitivity/competency/humility, which includes matters around unconscious and implicit bias, racism, sexism, homophobia, and the discrimination that results
What is health literacy?
Sometimes, it’s tough to know how to navigate the healthcare system. Many liken it to trying to read and understand a foreign language for which you have had no education.
With the release of Healthy People 2030, the CDC has enhanced the definition of health literacy:
- “Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
- Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”
According to the American Medical Association, poor health literacy is a stronger predictor of health than age, income, employment status, education, or race.
Health literacy plays a role in navigating the healthcare system and advocating for oneself or a loved one.
It is critical to note that reading literacy is not the same thing as health literacy. It also does not guarantee it. That means health illiteracy can impact anyone, regardless of their socioeconomic status or educational background. And the impact can be far-reaching, with implications for both quality and cost of care:
- increased chance of misdiagnosis
- longer time and more tests to make the correct diagnosis
- condition diagnosed at a later and potentially more deadly stage
- fewer preventive care visits and lower screening rates
- higher rates of hospitalization
- longer hospital stays
- higher utilization of the emergency room
- less engaged patient, or a patient perceived by a healthcare professional to be less engaged
- problems with care plan development and adherence
What are health disparities?
Health disparities are a particular type of health difference closely linked with social, economic, and/or environmental disadvantages. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on racial/ethnic group, religion, socioeconomic status, gender or age, mental health, cognitive, sensory, or physical disability, sexual orientation, and gender identity, and geographic location or other characteristics historically linked to discrimination or exclusion.
The National Institutes of Health define health disparities as “the difference in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups.”
What are Social Determinants Of Health (SDOH)?
According to the CDC and Health People 2030, “SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” The distribution of money and power shapes them as well as resources and the manner in which they are allocated at the global, national, and local levels.
The CDC has defined 5 SDOH domains:
1. economic stability
2. education access and quality
3. healthcare access and quality
4. neighborhood and built environment
5. social and community context
Examples of SDOH include socioeconomic status, the built environment, access to clean water and safe housing, food insecurity, food deserts (areas where there is limited access to a variety of healthful foods due to a limited income or living far away from sources of wholesome and affordable food), and food swamps (communities where fast food and junk food are overwhelmingly more available than healthy alternatives).
The importance of good nutrition to health and longevity is well-established. Structural inequities in the retail food environment and who has access to and can afford healthy fresh food contribute to inequities in nutrition-related health outcomes such as obesity, diabetes, and heart disease. This one example provides an idea of the degree to which SDOH can negatively impact a person, community, and society as a whole.
What are cultural sensitivity, competence, and humility?
The Office of Minority Health and Department of Health and Human Services describes culturally sensitive as care that which reflects “the ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage.”
Being culturally sensitive requires seeing each person as a unique individual. Being culturally sensitive and attuned to and collaborative regarding a patient’s health beliefs and traditions has been shown to positively impact adherence to treatment regimen recommendations and reduce health disparities.
Steps that can be taken to help increase cultural sensitivity include:
- being fully present and listening (not just hearing) to others with respect and without judgment
- asking questions to learn about the whole person and her/his preferences rather than making assumptions
- actively cultivating knowledge about other cultures
- acknowledging and paying attention to one’s prejudices and biases and the impact they can have on both verbal and non-verbal communication, medical decision-making, and the patient-provider relationship.
According to the Agency for Healthcare Research and Quality (AHQR), cultural competence in healthcare is “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of healthcare delivery to meet patients’ social, cultural and linguistic needs.”
According to the Robert Wood Johnson Foundation, cultural humility “requires you to step outside of yourself and be open to other people’s identities, in a way that acknowledges their authority over their own experiences….. By seeking to see someone in the way in which they identify instead of the way we might automatically categorize them, we are able to offer them the care they want and the care they need.”
Being fully culturally sensitive requires one to practice cultural humility. The two combined help you to continually become more culturally competent over time, and with increasing exposure to those who may have different lived experiences, health beliefs, and needs than your own, one’s cultural competence can increase.
Care delivered by those who are culturally sensitive and competent and show cultural humility results in a stronger patient-physician relationship, with greater trust and better health outcomes. And a strong patient-physician relationship typically leads to greater career satisfaction and less stress for the clinician.
When creating policies around cultural sensitivity, implicit and explicit racial biases should be considered, identified, and addressed. The Harvard Implicit Association Test (IAT) is a starting point to become more self-aware and attuned to implicit bias. However, every tool has its limitations. It is helpful to explore several opportunities* to learn and gain the skills to optimize the quality of care clinicians provide.
It takes genuine commitment to cultural understanding to truly see and understand patients beyond their symptoms.
Race and healthcare
Institutional racism is deeply embedded in the history of healthcare history in the U.S., including from a well-known professional society – the American Medical Association (AMA).
The organization is taking some steps to distance itself from its racist past, including decisions by Dr. Nathan Davis, who is considered the “father of the AMA”, to explicitly exclude women and Black physicians from representation in the organization. This decision reinforced local medical society policies which prohibited anyone but a white man from joining.
These policies continued even when a group of Black and white physicians pushed for change and asked to join the AMA. Despite support for the integration, including from another founding member of the AMA, Dr. Davis blocked the acceptance further promoting and embedding racism in the AMA.
Decisions throughout its 174-year history widened the gap toward achieving health equity and having a better representation of doctors that reflect the communities they serve.
Policy changes are addressing several issues, including racial bias in healthcare and the falsehood that genetic traits and biological differences define race.
James L. Madara, MD, AMA CEO and Executive Vice President, recently wrote to Congress, “Understanding that race is a social and political construct and not a risk factor for disease and death, the AMA has publicly acknowledged that racism impacts public health and is a barrier to effective medical diagnosis and treatment.”
And with the advent of artificial intelligence, which has already shown bias imbedded in some algorithms, clinicians must be attuned to tools used for patient assessment and decision-making.
Prescription for health equity
While health is the focus, the healthcare system is but one spoke in creating a holistic circle of care.
Social inequities matter more than healthcare in shaping disparities, according to the Robert Wood Johnson Foundation.
When equitably supported communities have the power to create opportunities so every resident can reach their full health potential.
However, barriers to these opportunities exist at every level of society – healthcare, education, employment, legal and justice system, housing, and transportation.
When the healthcare system and community make health equity a priority, the overall community’s well-being can improve far beyond just better health.
*Resources
1. How to Identify, Understand, and Unlearn Implicit Bias in Patient Care
2. The EveryONE Project Unveils Implicit Bias Training Guide
3. Implicit Bias Curricula In Medical School: Student And Faculty Perspectives
4. Implicit Bias: Recognizing the Unconscious Barriers to Quality Care and Diversity in Medicine
6. Racial bias skews algorithms widely used to guide care from heart surgery to birth, study finds
