Creating Equitable Health Outcomes for All — Part 2

For years, many have written about health disparities, with many authors citing the importance of healthy foods and exercise, and how self-care reduces risks attributed to non-communicable illnesses such as diabetes and heart disease. The medical system treats symptoms with a multitude of medicines that raise healthcare costs but leave people suffering because the system fails to treat causes. During the decades, many have failed to call out the underlying malignancy at the root of these diseases.

Racism creates illness. It’s the catalyst for poverty, homelessness, malnutrition, addiction disorders, violence, lack of access to preventive care, and high-level interventional misdiagnosis. Continued silence in the face of stark evidence encourages a status quo of neglect and inadequate care — a constant that kills. Throughout the generations, we have seen populations underrepresented in the care conversation. In public health, when we close our eyes to what is around us, death is invited into our communities. Health equity assumes that to address the urgencies of people’s care, doors are open to anyone with pressing medical needs. However, we now must recognize that this is not the case.

Among the most important solutions to addressing these vast public health challenges are the policies and processes we put in place around housing, hospital access and where we place employment opportunities. Reflects Rachel Hodgdon, International WELL Building Institute (IWBI) president and CEO:

Today, when it comes to Black and Latino people, we are behind in creating open, welcoming spaces that invite people to pursue career dreams and address health priorities. We are still drawing on a mindset from many decades past. For example, we have long heard the refrain “Blacks and Latinos are ‘predisposed’ to hypertension and diabetes.” As recently as 2011, authors wrote an article in the American Heart Association Journal Hypertension:

Studies have consistently reported a higher prevalence of hypertension in blacks than in whites, a main reason for the higher incidence of cardiovascular disease in blacks. The long list of putative causes for this higher prevalence suggests that the real reasons are still unknown. Biological differences in the mechanisms of blood pressure control or in the environment and habits of whites and blacks are among the potential causes. The higher prevalence of hypertension in blacks living in the United States instead of Africa demonstrates that environmental and behavioral characteristics are the more likely reasons for the higher prevalence in blacks living in the United States. They could act directly or by triggering mechanisms of blood pressure increase that are dormant in blacks living in Africa.

American Heart Association Journal (Hypertension)

Suggesting that the “real reasons” Black Americans experience a higher prevalence of hypertension, especially in comparison to Black Africans, are “still unknown” is blaming the victim. Perhaps the wording reflects an effort to be apolitical. But this is a conclusion that enables injustice to persist. Too many Black people in this country face poorer economic prospects than whites, poorer diet, and poorer access to care. No money, no healthy food, no decent care and no homes remote from areas that accrue greater value work net out quickly to a brutal cycle of poverty. And even the causes of these health disparities are only symptoms of the real, underlying condition: racism — no more and no less.

C. Virginia Fields, president and CEO, National Black Leadership Commission on Health, asks “Are we prepared as a nation to put in place systems that will address poverty, unemployment, racism? How do we address this through policies and budgets?”

Blacks are dying at a rate of 50.3 per 100,000 people, compared with 20.7 for whites. In New York City, the most densely populated place in America, 19% of residents — most of them people of color —live in poverty, while 17% live in overcrowded conditions. Is it any wonder then that the highest numbers of deaths from COVID-19 are among people of color who live in overcrowded conditions? And yet, the American Medical Association’s powerful report to its physician members — “Protecting public health & vulnerable populations in a pandemic” — discussed at-risk populations including the homeless, incarcerated, and impoverished, but failed to even mention people of color.

In the early 2000s, Dr. Jeffrey Brenner, who founded the Camden Coalition in New Jersey and now a voice for change within UnitedHealthcare, was determined to improve health care delivery in Philadelphia’s impoverished urban neighbor Camden. To do so, he pioneered the use of health care data to identify patients who needed frequent access to the city’s overtaxed and inaccessible medical system. Almost 20 years later he acknowledges that intensifying care to those with pressing needs is not enough. It requires a new mindset around health equity and safe space.

The key here is that navigation and coordination are important, but insufficient in and of themselves to improve outcomes.

Dr. Jeffrey Brenner

We must start with the fact that racism impacts health, even though it’s clearly the cause of multiple public health disasters. Going forward, our health system — filled with dedicated people who want to help sustain and save lives — must be mindful that structural and institutionalized racism are so entrenched that we have not seen them for what they are. It’s time to speak to and face reality: look closely enough and we see that health disparities come from racism; predisposition to disease comes from racism; poor access to care comes from racism.

This is among the many reasons why standards such as the IWBI health equity certification program are important to creating open and welcoming spaces for all people – but especially for people of color who have been shut out previously and have pressing needs.

The Robert Wood Johnson Foundation (RWJF) calls upon investors, planners, engineers and developers to be held accountable for creating places that support people’s health. Joining Dr. Brenner and IWBI’s Rachel Hodgdon, RWJF tasks decision makers to take into account four pressing questions in planning communities that address health equities:

  1. How can investments in urban revitalization and infrastructure advance health, equity and the public good?
  2. What are the key policy strategies and practices that address the roots of inequality and support healthier and more inclusive housing, transportation, utilities and open space systems?
  3. How can cities foster a shared sense of community to build infrastructure that serves the public interest?
  4. How can citizen science and data be used to promote equitable development and community-driven solutions?

Along with keeping these questions in mind, we must also recognize that the fight against racism is constant. It isn’t something that will ever be fixed once we reach a threshold; it is a process that those of us who are privileged and white must constantly work toward, but will never be through with. We need to push for policies and continued conversation to “Break the collective habit of racism and build resilience for racial equity in ourselves and our organizations,” as Dr. S. Atyai Martin, CEM, advocates in her book “We are the Question + the Answer.”

Only when we work to meet the needs of those whose needs are greatest can we make progress. On my part, I commit to actively fighting the epidemic of racism. Together, we must work to address the underlying cause of many of our public health crises with truthful words and actions that get to the heart of the problem.


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