The Urgent Need to Advance Health Equity: Past and Present

In 2020, the convergence of the COVID-19 pandemic and a national reckoning on racial injustice in the United States highlighted pervasive disparities, including glaring gaps in health care access and outcomes. ¹ But these disparities are generational, ² and serious concerns about inequities in health outcomes had been raised on numerous previous occasions by a wide range of federal and public health organizations. Nearly 40 years ago, then Secretary of Health and Human Services, Margaret Heckler, was compelled to convene a national Task Force on Black and Minority Health in response to her concern over health disparities. ³ Despite overall improvements in the multiple critical health metrics the U.S. had experienced, including infant mortality and life expectancy, she wrote: “But, and that “but” signaled a sad and significant fact; there was a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation’s population as a whole.” ³

The Task Force report opens with a summary of their charge, which reads:

“Despite the unprecedented explosion in scientific knowledge and the phenomenal capacity of medicine to diagnose, treat, and cure disease, Blacks, Hispanics, Native Americans, and those of Asian/Pacific Islander heritage have not benefited fully or equitably from the fruits of science or from those systems responsible for translating and using health sciences technology…The Task Force on Black and Minority Health was thus conceived in response to a national paradox of phenomenal scientific achievement and steady improvement in overall health status, while at the same time, persistent, significant health inequities exist for minority Americans. As the Task Force came into being in April 1984, it was evident that to bring the health of minorities to the level of all Americans, efforts of monumental proportions were needed.” ³

The Task Force recommended improved outreach and culturally tailored education on the leading causes of excess mortality (e.g., cancer, cardiovascular disease, diabetes); training of health care providers; innovative health care delivery and payment models; and intra-and extra-governmental collaborative efforts (e.g., with health professional organizations, state and local governments and agencies) to better meet the needs of members of racialized groups; improved collection and reliance on data; and the establishment of a research agenda to further explore disparities. ³

In 2003, in the face of persistent disparities, the Institute of Medicine produced what was widely viewed as a landmark report entitled Unequal Treatment. The report documented that quality of health care varied for members of different racial and ethnic groups, even after controlling for income and access to insurance. ⁴ Echoing Heckler’s Task Force, the authors called for a comprehensive, multi-level, multi-sector strategy to eliminate disparities in health care. They recommended policy and system change to increase health care access; payment reform; efforts to increase the proportion of practicing health care professionals from historically underrepresented racial and ethnic groups; enhanced training in culture-competence for clinicians; and improved patient education. ⁴

Yet, despite concerted efforts and investments in measurement and monitoring, research, and training, the Unequal Treatment at 20 Symposium ⁵ concluded that little tangible progress has been made to narrow those persistent health disparities between White Americans and those from racialized groups in the 20 years since the report.^6,7 Indeed, data for nearly every health outcome illustrate that we still have a very long way to go. ⁸ A recent review of data from 1999-2020 revealed that, compared to White Americans, Black Americans had more than 1.6 million excess deaths and more than 80 million excess years of life lost. ⁹ There are continued disparities in the prevalence of diabetes among different racial and ethnic groups: 7.4% of White Americans have been diagnosed with diabetes as compared to 11.8% of Hispanic Americans, 12.1% of Black Americans, and 14.5% of American Indian and Alaskan Native Americans. ¹⁰ There are also shocking disparities in maternal mortality rates, which are 2.6 times higher for Black women than for White women. ¹¹ And though Black, Hispanic, and White adults in the U.S. experienced similar rates of moderate to severe anxiety and depression in 2019, 64% of White Americans reported receiving mental health treatment vs only 45% of Black Americans. ¹² Disparities in treatment seeking for mental health concerns have been attributed in part to higher levels of stigma around mental health in Black and Hispanic racialized groups, structural inequities (e.g., health insurance coverage), and the lack of availability of mental health care providers of the same race, ethnicity, or cultural background. ¹³ Limited access to Black and Hispanic health care providers across specialties is in turn rooted in part in structural and systemic barriers that disproportionately impact members of these racial and ethnic groups. According to cross-sectional data from more than 81,000 Medical College Admission Test examinees, Black and Hispanic examinees were more likely to report educational and financial barriers, lower parental education levels, and discouragement from pre-health advisors than White examinees that resulted in a decreased likelihood of medical school application and matriculation. ¹⁴

While structural racism is a key contributor to inequities in our health care system,^8,15 racialized groups are not alone in experiencing health disparities. Efforts to advance health equity must be inclusive of all individuals, including members of religious groups that have been minoritized, persons with disabilities, persons living in rural areas, persons living in poverty, and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons.^16,17 As Bauermeister and Halem underscore in an article in this issue, LGBTQ+ individuals face significant disparities in health, ¹⁸ which may be partially attributable to challenges with health care access, discrimination, mistreatment, and harassment – particularly if they have multiple marginalized identities. ¹⁹ Increasingly, the gender-affirming care that could help address health inequities for transgender individuals is under attack from legislation. ¹⁸

There is hope, however, that we have finally – shamefully belatedly – reached an inflection point. There are signs of progress toward health equity on many fronts.

“Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health.” ¹⁶

More than 250 state or local leaders have declared racism a public health crisis. ²⁰ The Centers for Disease Control has adopted what they hope will be a transformative CORE Commitment to Health Equity to ensure health equity is the cornerstone of all of their work. ²¹ The objectives of that strategy are to cultivate the science of health equity, optimize interventions, reinforce and expand partnerships, and enhance and expand the capacity of the public health workforce. The National Institutes of Health (NIH) created a UNITE Initiative to catalyze action on health equity by elevating health disparities research; promoting equity within the biomedical research ecosystem and within NIH; and improving the accuracy and transparency of equity data. ²² The Robert Wood Johnson Foundation (RWJF) convened a Commission to Transform Public Health Data Systems that produced recommendations entitled Charting a Course for Equity-Centered Data System. ²³ RWJF also commissioned a comprehensive effort to examine structural racism in health care and to identify specific strategies for dismantling it through collective leadership. ¹⁵ Emphasizing that addressing health equity will necessitate the involvement of organizations, communities, and the private sector, The World Economic Forum’s Global Health Equity Network launched a global heath equity pledge to create a healthier and fairer world. ²⁴ More than 75 government agencies, academicians, corporations, and associations have committed publicly to contribute to the network’s collective vision of Zero Health Gaps. ²⁵ The American Medical Association has created a strategic plan to center racial and social justice within their organization and spheres of influence ²⁶ ; created a Center for Health Equity; and hired an inaugural Chief Health Equity Officer. Academic journals, such as Health Affairs, are also making a concerted effort to elevate and facilitate access to research on health equity. ²⁷ The American Psychological Association recently released new reporting standards for addressing race, ethnicity, and culture within psychological research and scientific manuscripts. ²⁸

Leveraging and catalyzing the increasing energy being invested in promoting health equity is essential in every aspect of our work as health promotion professionals. Critical components of our success will be adopting a community-centered approach^8,16,29 – beginning with communities who have historically been marginalized – and maintaining an unwavering focus on key principles and priorities of health equity. ¹⁶ The impact of all systems, policies, programs, practices, and communications must be evaluated through an equity lens.^1,16,30 The National Committee for Quality Assurance now offers Health Equity Accreditation for health care organizations – an example of how internal and external compliance standards can be raised to promote health equity. ³¹ It’s imperative to increase the representativeness of the health care workforce^32-35 and provide additional training and resources for all health care providers, solution developers, and decision makers^1,30 on persistent inequities and cultural humility. ³⁶ Joel Bervell is a Ghanaian-American medical student, science communicator, social media phenomenon, and podcast host widely known as the Medical Mythbuster. Later is this issue, he shares his powerful story about how he is battling disparities on TikTok and Instagram. In parallel with increasing the diversity of health care professionals, we must ask how we can shift power differentials and increase access to autonomy, opportunities, and resources to optimize health. ³⁰ There have been promising advances, for example, with the increased training and funding to increase access to community health workers. ³⁷

The time has come to re-evaluate our frameworks and models. Some have made a compelling case for using antiracism as a research framework ³⁶ for understanding and addressing cultural, structural, and interpersonal injustices that contribute to disparities. ³⁸ The implementation and rigorous evaluation of evidence-based health equity initiatives will require multiple data sources^8,39 and the specification of meaningful metrics that are assessed over time. ³⁰ Advocacy and civic engagement ¹⁸ will also be of crucial importance. The Congressional District Health Dashboard depicts health measures and their drivers to better inform community members, advocates, and policy makers with key data and highlight opportunities for improvement. Health care payment reform will continue to be of particular importance. ⁷

As Heckler’s Task Force noted so long ago, collaborations and partnerships^7,8,16,30 will be essential to drive real progress. National organizations are now teaming up to transform health care. The National Comprehensive Cancer Network, for example, has partnered with American Cancer Society Cancer Action Network and the National Minority Quality Forum to pilot a Health Equity Report Card to promote more equitable cancer care. ⁴⁰ The Health Equity Compact is an example of a statewide collaborative of 80 leaders who are galvanizing efforts to advance health equity. Earlier this year, the HLTH Foundation launched the Techquity for Health Coalition, the purpose of which is to identify and advance best practices in health equity specific to innovations and data practices for health technology. ⁴¹

The private sector has an important role to play, as is emphasized by a Forefront series being disseminated by Health Affairs. ⁴² The Black Directors Health Equity Agenda has created resources such as the Board Director’s Health Equity Playbook to provide a roadmap for advancing health equity within their organizations. ⁴³ As Calitz et al describe later in this issue, The American Heart Association has partnered with the Society for Human Resources Management and Deloitte Health Equity Institute to advance health equity in the U.S. workforce. Many of their recommendations will contribute to creating an organizational culture of health equity. ¹ Shepherd and Hines outline the comprehensive efforts that Metro Nashville Public Schools has undertaken to advance health equity. Their comprehensive approach relies on a best practices of ensuring benefits are optimized, easy to access, utilize, and understand.^1,44 Employers can also expand access to primary care and mental health care though virtual care or community partnerships, ⁴⁴ as well as invest in benefits that address unmet social needs.^1,44 Sherman et al highlight the role for human-centered design in health promotion program planning.

Margaret Heckler’s fervent hope was that the recommendations of the Task Force she convened would “…mark the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track record of ever improving health.” My fervent hope is that the multi-faceted efforts now underway are truly transformative enough to finally result in the actualization of health equity. It will require us all, and the time is now.