Life, Liberty, and the Pursuit of Health Equity

The COVID-19 pandemic has laid bare many troubling truths about the state of health and well-being throughout the nation, and perhaps none has been starker than the large disparities seen in the number of infections and mortality rates in marginalized communities. As lifelong learners and human experience researchers who are passionate about helping to improve the lives and outcomes of the populations we work with, we strive to understand the systemic and historical nature of health disparities, such as those made evident by the pandemic, and work to increase awareness of health disparities and racial equity while elevating the work of those with expertise and lived experience.

Health Disparities Between Populations

In this post, we share a broad overview of what health disparities and health equity are, who they affect, and what is being done to promote health equity. Per the CDC, health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations[1]. Simply put, a disparity exists whenever there is a difference in health outcomes between populations. These disparities affect not only specific populations but society as a whole in terms of overall population health and the costs of healthcare. In recent years, with the help of health disparities research, the tone has shifted from eliminating health disparities to achieving health equity – which is the attainment of the highest level of health for all people. Health equity research shows to do this requires valuing everyone equally, while recognizing and focusing on societal efforts to address systemic and avoidable inequalities and injustices and eliminating health disparities[2].

National Minority Health Month Highlights Efforts

April is National Minority Health Month, so we are focusing on the systemic disparities experienced by marginalized communities and people of color in their interactions with the health system, as well as highlighting the work being done to promote and increase health equity. While this post heavily focuses on health disparities across race and ethnicity, disparities exist across a broad spectrum – for example, urban vs. rural disparities, citizenship status, sexual identity and orientation, and more[3].

There are many fantastic resources discussing health disparities and health equity from various perspectives, and we have listed some of these at the bottom of this piece. We would like to highlight a few examples of health disparities and inequities in the social determinants of health that particularly affect the populations we serve in our work, specifically inequities in cardiovascular disease, maternal and infant health outcomes, and the impact of the COVID-19 pandemic. For a more detailed review, please click here.

Cardiovascular disease – While deaths from heart disease declined across all racial groups between 1999 and 2017, Black Americans still have much higher death rates from heart disease compared to non-Hispanic whites. Hispanic and Asian American, and Pacific Islander (AAPI) groups have the lowest death rates. However, white Americans have the highest overall rate of having heart disease – 11.5% compared to 9.5% in Black Americans[4]. Why, then, do Black Americans experience a higher rate of death from heart disease? Co-morbidities such as diabetes may be a factor, but here a paradox is seen. While Black Americans and Hispanics have similarly high rates of obesity and diabetes compared to whites, Hispanics have lower rates of heart disease and deaths from heart disease than either Black or white Americans.
Maternal and infant morbidity and mortality – Similar women's health disparities are seen in maternal and infant mortality. Black birthing people are three times more likely to die of pregnancy-related causes than white birthing people, and Black infants are twice as likely to die by their first birthdays as are white infants. Black women are also much more likely to suffer severe morbidity (disease or medical condition), with there being a reported 70 cases of severe maternal morbidity events to each maternal death. One study found that Black women experience severe maternal morbidity events at a rate of 2.1 times higher than do white women[5].

Why Do Differences in Outcomes Persist?

There is substantial evidence that Black Americans face discrimination and racism in healthcare settings, which can lead to poorer outcomes and even death. Some examples of this can be seen at the societal and community levels – more than half of Black Americans live in the South, an area that has largely refused to expand Medicaid, a vital source of health coverage for many. Additionally, in communities, residential segregation results in Black and Hispanic areas having lower access to quality health care. Social determinants of health also play a part – Black communities have historically been systemically marginalized and neglected and, therefore, may lack access to nutritious food, safe neighborhoods, affordable housing, reliable transportation, and more[6]. Outside of these societal factors, the burden of racism inflicts chronic ongoing stress and affects the ability for people of color to lead healthy lives. While stress itself can have significant physical impacts on health, Black people also experience differences in pain management and treatment of their conditions compared to White individuals, which can contribute to large differences in outcomes.

Racial Disparities in COVID-19 Cases

This year, the focus of National Minority Health Month is on the wide margin in racial disparities seen in the number of COVID-19 cases and deaths in marginalized communities compared to white communities and the efforts to increase vaccination rates in these communities. The pandemic has exposed the enormity of the disparities in health outcomes by race – compared to whites, Black, Hispanic, Native American, and AAPI populations have had substantially higher rates of infection, hospitalization, and death from COVID-19[7]. Some of these differences can be accounted for by the higher number of co-morbidities in these populations because those with chronic conditions such as diabetes and hypertension have experienced worse outcomes when infected with the coronavirus.

Missouri provides a case study on the disproportionate burden that the COVID-19 pandemic has placed on marginalized populations. High-risk, medically underserved communities, including racial and ethnic minority groups and those living in rural areas, have had a higher risk of exposure, infection, hospitalization, and mortality compared to white communities. Although only 16% of Missouri’s population identifies as a racial/ethnic minority, over 30% of confirmed COVID-19 cases have occurred in this population, significantly higher than would be expected [8] . The effect of social factors. Studies have indicated that inequities in social factors – which are inextricably tied to race and ethnicity in the U.S. – have played a major role in the disproportionate burden that marginalized communities have faced, particularly during the COVID-19 pandemic [9] . When differences in income, neighborhood, healthcare access, and insurance access are adjusted for, there is no significant difference in COVID-19 mortality between Black and white Americans. The disparities seen in the social determinants of health between minority and white populations, therefore, play a significant role in health outcomes, and these factors were exacerbated by the pandemic. As noted recently by a Kaiser Family Foundation policy brief, “Health disparities are a symptom of broader social and economic inequities.” [10]

However, health disparities research identified disparities in health outcomes persist even beyond differences in the social determinants of health and are a result of ongoing racism and discrimination faced by people of color when interacting with the health care system. For example, recent research has shown that stark differences in maternal and infant outcomes between Black and white Americans persist, even when researchers control for social factors such as insurance status, income, and education[11]. One study highlighted by the Kaiser Family Foundation found that BIPOC women reported significantly higher rates of mistreatment, such as being refused assistance or treatment, yelling/scolding, and being ignored[12]. Other research has shown that maternal outcomes for Black women and infants improve significantly when cared for by Black providers[13] and that many women feel they are treated unfairly, felt their providers didn’t believe them, or that they were denied treatment due to their race[14]. The lack of fair, unbiased, quality healthcare that many people of color feel they receive can lead to mistrust in the healthcare system and hesitance to seek treatment or care, which can result in poorer outcomes.

Health Disparities Between Populations

Next steps. There are many steps that can be taken by communities, healthcare networks, and policymakers at local, state, and federal levels that would work towards decreasing racial disparities in healthcare and increasing health equity, a few of which are summarized below.

Working deliberately to address systemic barriers to health equity and the social determinants of health
Protecting and expanding access to health insurance, through the ACA, Medicaid, or more ambitious policy proposals such as Medicare for All, single payer, or a public insurance option
Supporting the implementation of evidence-based policies and practices that address the social determinants of health and the effects of racism on minority communities
Ensure healthcare providers and staff are trained in cultural competency
Increase access to community-based providers and safety net programs

While there has been some progress, much work remains in increasing health equity. By promoting awareness of these issues, we hope to draw attention to the health equity research and other work that still needs to be done. Although these challenges may seem daunting, there are many health disparities research efforts, resources, and partners available for anyone who wants to take action and support efforts toward eliminating health disparities. The Root Cause Coalition, a nonprofit whose goal is to achieve health equity for every American, recently concluded their 2020 Status of Health Equity Report with a Call to Action for improving the nation’s health with the following statement: “The solution to creating a healthier society does not rest on the shoulders of one sector, but requires each of us – from business, social services, health care, government, education and more, to work collaboratively.”

The opportunity to attain the highest level of health should be an inherent human right. Here are some additional resources for further information and work being done on these issues:

Author's note: Creating an environment where everyone has equitable access and opportunity to realize their full potential means being part of difficult conversations and confronting issues with deep historical roots and systemic mechanisms that uphold those inequities. The Simply Strategy team recognizes that the language we use is part of this challenge – for example, many of the articles and resources cited here consider whiteness to be the “default”, and all other populations to be the “other”. This language limitation is something that we currently don’t have clarity on how to do better, but we acknowledge this barrier and will continue as learners in this space.

References