Abstract
Early in my career, I delivered babies. Hundreds of babies. During each birth, I spoke with expectant mothers, partners, and family members about their hopes for the new lives entering the world. Regardless of the education of the family, their income, or race, the conversations were the same. They prayed first for the health of the child—10 fingers and 10 toes—and then for joys and opportunities that far surpassed their own.
In these moments, it was clear to me that we human beings are so much more alike than different.
When children enter this world, however, their realities are different. I know this from my own experience as a Black woman, married to a Black man, raising 2 Black children, and as the daughter of immigrants. I also know this as a physician who has spent my career navigating inequities that manifest daily in my practice. For illustration, if we follow 4 babies from 4 different backgrounds, we can see how health inequities appear and potentially lead to 4 very different outcomes.
For babies who are Native American or American Indian, inequity shows up in infant mortality rates 1.5 times higher than a White baby. 1 Hispanic babies have higher rates of preterm birth or low birth weight than their native-born counterparts. 2 Black babies, like my own, are almost 3 times as likely as White infants to die before they reach their first birthday. 3
And all those mothers offering up the very same hopes and dreams are subject to drastically different outcomes, as well. The mothers of Asian American and Pacific Islander babies are more likely to experience postpartum hemorrhage and perineal lacerations than White mothers. Black mothers are twice as likely to receive late or no prenatal care compared with White mothers. 4
As these babies grow into adulthood, inequities widen. Native American populations have 50% higher rates of binge drinking, drug abuse, and death from suicide and cirrhosis. 5 The Hispanic adult is 50% more likely to die from diabetes or liver disease, and to struggle with obesity and asthma. 6 As an adult, the Asian American or Pacific Islander will be more likely to have Hepatitis B and twice as likely to die from stomach and liver cancer. 7 Blacks have the highest rates of hypertension and diabetes among all adult populations. 8
Unfortunately, not even education and income can close these gaps. Maternal deaths are more common, in fact, among Black women with a college education than White mothers without a high school diploma. 9
COVID-19 in Communities of Color
When the COVID-19 pandemic initially ravaged American communities, communities of color were the hardest hit. To explain the disparity, we can point to a range of what might be considered “midstream factors” that influenced that “downstream effect,” such as crowded housing conditions, unemployment, limited economic mobility, and poor access to health care that put Black and Hispanic groups at risk. When we move further upstream, however, we see the more foundational roots of this inequity, specifically the entrenched structural racism that shapes the policies that ultimately shape the health outcomes. Indeed, the history of racism and slavery may just be one of the most intransigent legacies of the American experiment.
Racism in American Health Care
In the early 1600s, coinciding with the origins of American slavery, François Bernier published an essay dividing humanity into “races,” and making the case that black bodies were biologically inferior to white bodies. This commodification of black bodies evolved into the use of those bodies for medical testing and discovery, most notably in the 19th and 20th centuries in the fields of gynecology and infectious disease.
At the turn of the 19th century, W.E.B. Du Bois penned The Philadelphia Negro, one of the first polemics challenging the health-as-biology argument, contending that the health of Black individuals was an outcome of living conditions, not genetic composition. His essay fell on deaf ears. Even after the official end of slavery, forced sterilization of Black women was legalized in states nationwide, followed by the 40-year Tuskegee Study to involuntarily infect and then observe Black men with syphilis.
Meanwhile, as though this patent racism is a vestige of the past, half of medical students still believe the myth that black and white bodies are biologically different. 10 And a 2021 compilation of structural racism-related state laws that influence health outcomes found that most states have kept laws on the books to disproportionately discriminate against racial and ethnic minority groups. 11
Addressing the Counter Argument
I want to address those who would argue that these health disparities are an outcome of the choices and/or biology of individuals. That belief often coexists with a similarly fierce confidence in the greatness of our nation and a tenacious embrace of self-determination. I, too, believe in both our nation and the power of agency.
But if it were true, for example, that a multidecade difference in life expectancy between Blacks and Whites was biologically determined, then that difference would be consistent globally. Black men in Ghana would die, on average, 25 years earlier than Whites in Ghana, just as Black men in Chicago die nearly 3 decades earlier than their White counterparts. That is not the case. Wide gaps in race-based health outcomes is a uniquely American phenomenon.
The fact is, America is falling behind and failing everyone when we perpetuate a health system that renders growing portions of the population sick, and thwarts the vitality of our economies, communities, and that spirit of self-determination in which we believe.
A New Quadruple Aim
So how do we both acknowledge these wrongs and set a new course forward?
The World Health Organization defines health equity as the elimination of unnecessary, avoidable, and unjust differences in health and health care, which can be based on background, resources, and systemic factors such as racism and discrimination. It can also be defined by health inequity, as we saw in the case of the 4 babies earlier in this article.
Health care systems are uniquely positioned to address health inequity in all its forms. In fact, I contend that we have an ethical, moral, and professional obligation to do so. Some promising movement is happening now to begin that process.
In 2014, Thomas Bodenheimer, MD, MPH, and Christine Sinsky, MD, recast the familiar Triple Aim that has long guided health care delivery, positing that effective care needed a fourth component: provider well-being. This revised Quadruple Aim has become the gold standard in health care, prioritizing patient experience, reducing costs, addressing population health, and tending to the providers who deliver that care.
I believe it is time to revisit this framework, because we cannot adequately achieve any one of those factors without keeping health equity at the core of all our work. How can we, for example, claim to put the patient first if our Black and Hispanic patients continue to die from preventable conditions decades earlier than Whites? And, when these very conditions put more pressure on providers and thus undermine their own sense of ethics and professionalism, is it any surprise that burnout and moral injury is endemic among practitioners?
In 2021, I authored an article with my colleague, Mark Rastetter, MD. In it, we argue that it is long past time to move health equity from a desired outcome of the Quadruple Aim to its essence.12 This recalibration requires us to first come to terms with a history and a present where health equity has been either an afterthought of care or expressly excluded from our calculations. As we confront these painful truths, policies and programs will undoubtedly need to be redesigned with the communities we serve. From the algorithms we employ in care delivery to the services we embed in neighborhoods, applying a health equity lens is the only way to change how we work and to be fully inclusive of race, ethnicity, gender, gender identity, sexual orientation, religion, geography, educational attainment, literacy, economic status, and so many more of the markers by which we self-identify.
The Path Forward
This process of reorientation has already started in health systems nationwide. As the first Chief Health Equity Officer at Humana, Inc., I am heartened by the implementation of a health equity lens in every business line we operate, from evaluating where we source goods and services to mapping the consumer journey to see where improvements can be made. We are disaggregating data to understand the intricate differences between health and health outcomes within different populations, then working with those populations to tailor solutions that mitigate disparities.
This study demands creative and extensive community engagement, particularly among those who have been historically disenfranchised. We are also integrating the understanding of social needs of our members and patients and designing programs and benefits that meet those needs. We are leveraging big data and artificial intelligence to predict and prevent problems before they occur. Finally, we also own the fact that some health inequities are rooted in our own implicit biases that can only be dismantled through training and tools on cultural competency, cultural humility, and implicit bias that we are now implementing enterprise wide.
All of this is predicated on shifting from sidelining efforts for the most disenfranchised to, as Black and Rahman shared in their framework, actually centering the work we do around those made most vulnerable—all of those who are historically at the margins of care.
Although the last baby I delivered was my own (now pre-teen) daughter, I doubt much has changed around the hope of parents toward their little ones. I also believe we all want our babies, our future—including those 4 babies earlier who may not share our histories and identities—to attain joys and opportunities that are so much greater than we experienced and to achieve their fullest potential in all domains. We have the tools to do this. With the commitment of so many of us in health care, and the momentum we have garnered for health equity these past 2 years, I believe we will. As Oprah Winfrey famously stated: “None of us in this world have made it until the least among us have made it.”
Footnotes
Author Contribution
The author led all research and development of the article.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.