The year 2020 was historically marked by the COVID-19 pandemic, economic collapse and activism for racial justice sparked by the murders of Breonna Taylor, Ahmaud Arbery, Rashard Brooks and George Floyd. The COVID-19 pandemic clearly demonstrated that African-American, LatinX and other at-risk communities suffered a disproportionate number of coronavirus-related infections, hospitalizations and deaths per capita. Similarly, substantial research over decades confirms that these same at-risk communities suffer disproportionate numbers of chronic illnesses like hypertension, diabetes and obesity. Furthermore, these communities have poorer health outcomes.
Unfortunately, the societal response to these health inequities and disparities have been either muted or ignored. The documented COVID-19 associated racial and ethnic disparities along with protests and activism for racial justice highlighted the fact that systemic racism is a public health issue and embedded in healthcare.
Racism is more than hating a group of people because of their skin color. Racism is the political power structures, systems, laws and policies that have historically sustained privilege and supremacy and has been embedded throughout society since chattel slavery. Structural racism is a fundamental cause and creates the sustained “frame of permission” to drive health inequities and health disparities. (See Figure 1.)
Equity is the absence of avoidable, unfair or remediable differences among groups of people, whether those groups are defined socially, economically, geographically or by other means of stratification. Health equity implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential. Health disparities are preventable differences in the burden of disease, injury, violence or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic and other population groups and communities.
Health inequity is related to the legacy of overt systemic racism on the part of society as well as present-day practices and policies in our public and private institutions that perpetuate a system of sustained and diminished opportunity for at-risk populations. Health equity is not singularly placed-based. It is best holistically viewed through the lens of the social determinants of health.
The social determinants of health are defined by the World Health Organization and the Centers for Disease Control and Prevention as “the circumstances in which people are born, grow up, live, work, pray, age and the systems put in place to deal with illness” that are shaped by the “distribution of money, power and resources at global, national and local levels.” The social determinants of health include education, healthcare, social-community context, neighborhood-environment and employment. Historical, systemic and structural disproportionate distribution of these social determinants, along with uneven assignment and barriers to the political determinants of health, which include voting, government and policy, are the key drivers of health inequities and subsequent health disparities. (See Figure 2.) A person’s zip code, which reflects these determinants, is a better predictor of health status and life expectancy than an individual’s genetic code.
The intersectionality and interconnectedness of the social and political determinants of health help to identify root causes of common and persistent inequities and can provide a framework for evidence-informed interventions, practical metrics for benchmarking and strategic tools to address these inequities.
Take for example the following scenario that is evident in many communities across the United States. Discriminatory zoning laws have historically placed African-American communities in proximity to toxic industries that lack economic opportunity and mobility. These communities are plagued by systemic disinvestment and under-resourcing in public schools. Poor education attainment and low graduation rates correlate highly with poor employment options and poor health outcomes. Limited greenspace and food deserts are common. Housing conditions are often substandard, crowded and multigenerational. Broadband connectivity is often lacking.
Residents of these communities often display a higher incidence of unhealthy behaviors like smoking, lack of exercise, poor health literacy and poor dietary habits. Access to healthcare is often limited. These cumulative adverse experiences or “weathering” cause chronic stress and chronic illnesses. The convergence of economic, food, housing and educational insecurity is rooted in racism and are key drivers of health inequities and disparities. Historically exhausted and vulnerable African-American and other at-risk communities have been abandoned, neglected and ignored centuries before the COVID-19 pandemic.
What then are the strategies to invert the burden? Both individual and institutional mitigation strategies are needed. (See Sidebar.)
We must have the moral courage to step away from “bystander silence.” Racism in medicine must be acknowledged by all. When left unchecked, “bystander silence” leads to blaming the victim, further perpetuating the cycle of racism. Additionally, colorblind and race-neutral approaches don’t address root causes of privilege, power and supremacy.
Systemic racism has led to the development and perpetuation of implicit biases (individual and organizational), microaggressions, stereotypes and prejudices that exist in medicine today. Development of meaningful curricula in medical and graduate medical education are required. Ongoing educational and professional development for healthcare providers in topics like anti-racism is needed.
Evidence has documented that the historical lack of racial and ethnic diversity in the pool of physician trainees, researchers and other members of the healthcare workforce contributes to health disparities. In particular, racial and ethnic minorities continue to be severely underrepresented in the physician workforce. Programs that identify, train and mentor members from underrepresented groups must remain a high priority to reach a goal of workforce diversity, which is critical to achieve a goal of health equity. Meaningful “pipelining” must be accomplished.
Creating proximate, cross-sector partnerships is required to fully address the impact that the social and political determinants of health have on health inequities and disparities. Current concepts like “food as medicine,” “housing as medicine,” and medical-legal partnerships underscore this reality.
Convening a coalition of corporate, healthcare system and payor, academic, philanthropic, faith-based, government and entrepreneurial partners is essential to accomplish this work by making investments and creating infrastructure that is tailored, community-facing and culturally competent. Trusted health equity data, key performance indicators and metrics that measure and track progress on the social determinants of health must be created to set priorities and inform necessary interventions that achieve impact, embrace the urgency of today and will be sustained in the long term.
Furthermore, enacting policies that improve equitable site and access to high-quality clinical care are essential to advance health benefit to all and thereby reducing health disparities. Community engagement and sustaining community trust is also required. A strategy to provide resources is necessary but not sufficient.
Fundamentally, there must be an acknowledgment that race is not a risk factor for health inequity and disparity. The risk factor is racism. Unfortunately, with respect to racism in medicine, “what’s past is prologue.” It is critical to prioritize and center racial equity if we hope to make meaningful change to health equity. Reimagined, deliberate action is required to stand in the storm and bring the underserved out of the shadows of invisibility.
Dr. Jeffrey F. Hines is Medical Director, Diversity, Inclusion and the Center for Health Equity, and Chief, Division of GynecologicOncology for Wellstar Health System in Marietta, GA.