From The Field M A Y 1 9 , 2 0 1 5 Health Equity and Social Justice: A Health Improvement Tool GEORGES C. BENJAMIN, MD Executive Director, American Public Health Association I feel obligated to begin with a warning: this essay may get a good example: 50 years ago, President Lyndon Johnson uncomfortable. It is simply impossible to talk about the signed the Medicare program into law. A year before, passage roles that racism and discrimination play in the health of of the Civil Rights Act prohibited the use of federal funds by our communities without taking a hard look inward—without programs or organizations that engaged in racial segregation or asking ourselves and our colleagues to think about the ways discrimination. Combined, the two federal measures led to that our institutions and organizations perpetuate bias and more than 1,000 hospitals integrating their hospitals and historical trauma. Perhaps more than most fields of work, medical staff. Today, every older American has access to the public health is paved with good intentions, with the worthy health care system and yet, serious disparities persist. For goals of alleviating suffering and extending life. But we are at a example, older black Americans still have higher rates of point in public health history in which good intentions and premature death from diabetes and often receive a lower good science are no longer enough. We must listen more to quality of care. They also face a higher risk of disability than the people we serve, have uncomfortable conversations, and older white Americans, while older American Indians and increase our push for social justice. Alaska Natives often face the highest rates of disability among Let me explain. Today, the biggest threats to the health and all population groups. Only one-half of older Hispanic longevity of Americans are preventable diseases. These are the Americans have received the pneumococcal vaccine. diseases that are burying us in preventable suffering, as well Why is this? Why do we continue to see such disparate as crippling our communities with mountains of avoidable health outcomes across our communities, despite our efforts to medical bills. The root causes of many of these health threats widen access to the best medical care in the world? This is a are inextricably linked to the social determinants of health monumentally important question, especially as the Patient and the conditions that shape a person’s opportunity to Protection and Affordable Care Act expands access to millions attain good health and adopt healthy behaviors. These social of previously uninsured Americans with an ultimate goal of determinants include access to safe housing, good jobs with universal insurance coverage. How do we translate access for living wages, quality education, affordable health care, all into health for all? The answer is health equity, which is nutritious foods, and safe places to be physically active. They intrinsically linked to acknowledging the long-lasting effects of also include racism, discrimination, and bias. our history, allowing that acknowledgement to shape our If we travel far upstream to uncover the roots of disease and dis- interactions with disadvantaged communities, and actively ability—and by that same token, to uncover the roots of today’s looking for ways in which our institutions and systems may persistent health disparities—the roles of racism, discrimination, perpetuate bias and historical trauma. and bias in perpetuating generational cycles of poor health and According to Paula Braveman and Laura Gottlieb in a 2014 risky health behaviors are easier to see. It is easy to see how the article in Public Health Reports: blatantly discriminatory policies of our nation’s past made it Health equity means social justice in health (i.e., no one impossible for certain groups of Americans to attain optimal is denied the possibility to be healthy for belonging to a health. What is much harder—and oftentimes uncomfortable— group that has historically been economically/socially dis- is to realize that the legacy of our history did not disappear with the signing of new laws. It is uncomfortable, but we must con- advantaged). Health disparities are the metrics we use to tinue to confront and acknowledge that history if we truly want measure progress toward achieving health equity. A reduc- to eliminate health disparities and create a nation in which every tion in health disparities (in absolute and relative terms) is person has the opportunity to live a long and healthy life. evidence that we are moving toward greater health equity. SOCIAL JUSTICE AND HEALTH: ACHIEVING Social justice, on the other hand, is defined as “justice in HEALTH EQUITY terms of the distribution of wealth, opportunities and privileges within a society,” according to the New Oxford I believe that one of our biggest misconceptions—and American Dictionary. Ensuring social justice is therefore one perhaps, obstacles—is misconstruing access for equity. Here is component to achieving health equity. The research on the intersections between health, racism, and open, honest discussions about the role of government in discrimination is plentiful. Here are just a few examples. perpetuating inequities among Native people. Today, the A 2013 study published in the Maternal and Child Health outcome of those discussions is known as the Future Journal examined the perceptions of prenatal care among black Generations Collaborative, a truly community-driven effort women with limited incomes and found that the “majority of in which acknowledging the role of historical trauma and women described experiences that fit within a definition of oppression is essential to shaping effective health interventions. institutionalized racism in which the system was designed in a In the APHA report, the collaborative’s project manager way that worked against their attempts to get quality prenatal within the health department said: care.” In particular, many women felt they were treated If we really want to get to a place of health equity, we have differently based on their race or whether they had private or to dismantle the systems that are preventing communities public health insurance. A 2004 study published in the from reaching their full potential. That means examining American Journal of Public Health actually concluded that how our systems perpetuate inequality....The first day I self-reported experiences of racial discrimination were associ- was able to completely abandon my own agenda was the ated with preterm birth and low birth weight deliveries. A day I became a transformed professional. number of studies have found that daily experiences with bias and discrimination contribute to chronic stress among racial Seeing health through a health equity lens means listening to and ethnic minorities, which may contribute to higher rates of those we serve and acknowledging their experiences. It means chronic illness. Another study published this year in the Journal looking deep inside ourselves and our institutions, no matter of General Internal Medicine found that experiences of discrimi- how uncomfortable the journey. The march toward health nation within health care settings were associated with new or equity will be a long one, requiring the support of players worsening disabilities among older patients. across private and public sectors. But at the end of the day, Outside the world of academic journals, our struggles with health equity is the ultimate form of patient-centered care. race and equality are painfully obvious as well. The recent series of deadly altercations between law enforcement officers and unarmed black men are raising the consciousness of Americans to the corrosive nature of racism and discrimination on the SOURCES well-being of communities and the need to achieve social justice as a component of any effort to achieve health equity. American Public Health Association (APHA). Better Health Public health has a vital role in the health equity move- through Equity: Case Studies in Reframing Public Health Work. ment. Our long-time connections to the communities we Washington, DC: March 2015. http://www.apha.org/~/ serve and our deep understanding of the connections between media/files/pdf/topics/equity/equity_stories.ashx. individual health and community conditions are essential to achieving equity and eliminating health disparities. However, Braveman, P., and L. Gottlieb, “The Social Determinants of even within the public health field, making an earnest shift Health: It’s Time to Consider the Causes of the Causes,” in toward health equity means having that “uncomfortable” Nursing in 3D: Workforce Diversity, Health Disparities, and conversation—we must also look inward and ask how our Social Determinants of Health, Public Health Reports 129, actions may perpetuate feelings of exclusion among the most Supplement 2 (January/February 2014): 19-31. vulnerable. How can we build relationships of genuine trust? Mustillo, Sarah, Nancy Krieger, Erica P. Gunderson, Stephen The American Public Health Association (APHA) recently Sidney, Heather McCreath, and Catarina I. Kiefe. released a new report on health equity that tells the stories of five “Self-Reported Experiences of Racial Discrimination and health departments and communities that have committed to Black-White Differences in Preterm and Low-Birthweight achieving health equity. I think one of those stories, in particular, Deliveries: The CARDIA Study.” American Journal of Public is a perfect example of how committing to health equity requires Health 94, no. 12 (December 2004): 2125-2131. real transformation. The story takes place at the Multnomah County Health Department in Oregon, where health workers Rogers, Stephanie, Angela D. Thrasher, Yinghui Miao, W. John had set out to tackle poor birth outcomes and high infant Boscardin, and Alexander Smith. “Discrimination in Healthcare mortality rates within the American Indian and Alaska Native Settings is Associated with Disability in Older Adults: Health community. They did everything one would expect: collected and Retirement Study, 2008–2012.” Journal of General Internal and analyzed the data, applied for grant funding, and sought out Medicine. 2015. DOI: 10.1007/s11606-015-3233-6. support from the local Indian Health Board. But once they actually went into the community to engage local partners, Salm Ward, T.C., M. Mazul, E.M. Ngui, F.D. Bridgewater, everything began to fall apart. They quickly realized they had and A.E. Harley. “‘You Learn to Go Last’: Perceptions of overlooked the most critical aspect: trust. Prenatal Care Experiences among African-American Women The health workers had no relationship with the people with Limited Incomes.” Maternal and Child Health Journal 17, they hoped to help—they were another government entity no. 10 (December 2013): 1753-59. coming in with a top-down, predetermined agenda. They had no institutional knowledge of how to effectively partner with the Native community. So they let go of their agenda and Views from the Field is offered by GIH as a forum decided to simply listen to the community’s stories and have for health grantmakers to share insights and experiences. If you are interested in participating, please contact Osula Rushing at 202.452.8331 or orushing@gih.org.