Black Americans face disproportionately high rates of poor health outcomes across most illnesses: diabetes, hypertension, heart disease, asthma – to name a few.
For most cancers, Black Americans’ death rates are higher than other racial groups and their survival rates are shorter. Black men have the highest rates of prostate and colorectal cancer compared to other racial groups, and the number of patients under age 50 is rising.
Black women are more likely than white women to die of breast cancer despite being diagnosed at similar rates. And during pregnancy, the death rate for Black women in the U.S. is comparable to developing countries despite technology advancements.
These health disparities linger because of structural racism embedded within the health care system and in the environments where people live, work, play, and worship. The issue was thrust to the forefront of health discussions as the COVID-19 pandemic turned the nation’s attention toward the disproportionate toll of the virus — and other chronic illnesses — on Black America.
Since then, the inequities reported in coronavirus-related hospitalizations, deaths, and vaccination rates have allowed experts to shed light on the meaning behind “health equity” — the idea that everyone should have a fair opportunity to live a healthy life.
“Health equity is achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances,” according to the Centers for Disease Control and Prevention.
Health experts and local organizers are working to better understand and remove the barriers to equitable health outcomes. But right now, the persistent racial disparities in life expectancy, rates of disease, severity of illness and death show that health equity is more of an ideal than an accomplished goal in medicine.
“Health is much more than medical care,” said Dr. Carla Williams, an associate professor of Medicine and Public Health at Howard University. “We have to talk about our neighborhoods, environmental factors, such as exposure to toxins, and even the education system.”
Inequities in health and wellness are largely caused by the systems that affect people’s health, not biological differences. Genes don’t cause racial disparities – society does. That means many of the documented racial disparities are preventable, and thorough research and comprehensive policy changes are powerful tools in improving outcomes for Black Americans.
Health equity’s origins
The concept of health equity has international roots based in social medicine. In 1946, the World Health Organization wrote the concept into its constitution.
The “highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition,” the constitution reads.
The intention behind health equity was — and still is — to eliminate avoidable differences in health outcomes.
The Heckler Report – released in 1985 by a task force commissioned by Secretary of Health and Human Services Margaret Heckler – marked the first time the U.S. government officially convened health experts to study racial and ethnic minority health. It captured a snapshot of health disparities across the nation.
Since then, research conducted around equity in medicine has expanded, offering health experts a deeper glimpse into what is driving disparate outcomes by race.
To address the disparities, making a distinction between “equity” and “equality” is key. Equality focuses on giving everyone the same access to care, while equity varies resources based on individual needs. Equity takes into account that more vulnerable communities have additional barriers to being healthy and provides them with more support than in communities with greater resources.
Equality would give all patients equal access to cancer screenings. Equity would focus on factors that influence a patient’s ability to get cancer screenings at the outset, such as insurance, ability to fund treatment, safe and reliable transport to get to appointments, and obstacles like cultural stigmas or language barriers.
“The starting point has to be fair and reasonable,” Williams said.
Equity aims to remove systematic barriers and create an equal opportunity to be healthy regardless of race, gender, or socioeconomic status.
“We have to make adjustments and provide different resources for different individuals and groups based on their personalized needs,” she said.
The role health equity plays in everyday life
To get a clear picture of what’s influencing people’s health, you have to look outside of traditional medical institutions, said Natasha Williams, an associate professor of population health at New York University. Circumstances like availability of affordable housing and health foods, exposure to violence or toxic waste, and access to safe, open-air parks affect people’s well-being.
So does racism.
“The day to day, constant experience of discrimination, or even the threat of discrimination, will impact your physical and mental health,” said Williams. That added stress can increase blood pressure, inflammation and heart rates, and it can disturb sleep.
These stress factors, which encompass the ways people interact with their environment and community, are referred to as social determinants of health.
The racism and unconscious bias baked into traditional medical institutions further compounds the inequities outside of the healthcare system. Dismissing Black patients’ pain is one of the ways bias impacts care. Researchers found that Black emergency room patients were 40% less likely to receive pain medication than white patients, according to a 2019 study.
How research and policy influence health inequities
As the number of Black patients falling victim to the coronavirus rapidly grew during the pandemic, many health equity researchers pivoted from their career-long specialties in areas like cancer research and maternal health to investigate COVID-19.
The virus was a perfect, real-time example of how complex and deeply entrenched health inequities are across the country. Black Americans remain twice as likely to die from the coronavirus — a trend driven by disparities in pre-existing conditions and an enduring lack of resources in communities most vulnerable to disaster or disease outbreaks.
As Americans consider what returning to a sense of “normal” looks like as caseloads of the omicron variant drop, public health and medical experts are studying the best ways to protect Black communities from continuing to bear the brunt of devastating health outcomes.
They are pointing to policy changes and increased accountability for ensuring equitable health outcomes. Decisions like where to place crosswalks, the density of fast-food restaurants in a community, school policies for subsidized meals, and zoning laws for housing, all factor into health equity.
“All of these are policy decisions that impact health and can easily change the health of a community or an individual for better or worse,” Alden Matthew Landry, the assistant dean for diversity at Harvard Medical School, wrote in an email.
Some national legislation passed in recent years adds a layer of accountability for researchers and medical professionals. The Henrietta Lacks Enhancing Cancer Research Act, signed into law by former President Donald Trump, aims to reduce barriers for people in racial minority groups to take part in clinical trials. To do so, it requires that the federal government report the amount of participation by underrepresented groups in government-funded cancer research trials.
The bill was inspired by Lacks, a Black woman whose cells were used for research without her consent in the 1950s.
Health equity efforts require information and discussion about how race affects Americans’ experiences in various parts of their lives – an awareness that is being squashed in statehouses across the country.
“Policy can be a double-edged sword,” said Alicia Best, an assistant professor in the University of South Florida’s College of Public Health, pointing to Florida’s recent move to restrict teaching about race in schools.
Florida Gov. Ron DeSantis has backed a bill that would bar public schools and private businesses from making people feel “discomfort” about history because of their race, nationality or gender. He has also proposed a Stop WOKE Act, which aims to limit education on critical race theory. It’s part of a wave of similar legislation across the country, including in Texas and South Dakota.
“This kind of legislation undermines the ability to address health inequities,” said Best.
The barriers to achieving health equity
Many experts blame the structural racism ingrained in various aspects of daily life for the persisting inequities in Black Americans’ life expectancy, rates of disease and death, and access to treatment.
Another factor in those persistent inequities is limited access to race and ethnicity data. In nearly half of the nationally reported data on coronavirus cases and hospitalizations, race and ethnicity is missing, according to a report by the federal COVID-19 Health Equity Task Force, making it difficult for researchers to identify inequities and adequately address them.
The issue prevails across health data beyond the coronavirus.
“If you don’t collect simple demographic information in a way that recognizes diversity,” said Williams, the Howard professor, “you are going to cause people to be invisible and you’re not going to know where those inequities and disparities exist.”
Inclusive data collection that allows individuals to report preferred language, migration history, ethnicity, disabilities, and gender identity is essential to identifying barriers to equitable health outcomes, she said.
“The stride that we’re making so far is that there’s a recognition that we need to address systemic issues,” she said, “but we’ve still got work to do in actually remedying them.”