Driving Real Change in Community Health
2020 has created a new urgency around investing in community health as a bedrock of individual and community quality of life. This year, disease and death data coming from the COVID-19 pandemic, alongside discussions around structural racism after the death of George Floyd, have reshaped the conversation.
The pandemic showed the vulnerable underbelly of health disparity. It became clear people of color and low-income populations disproportionately became infected and died. In fact, Black, Hispanic and American Indian people have been 2.5 times more likely to contract COVID-19 than white people and five times more likely to be hospitalized.1
Deaths from coronavirus largely align with the overall racial composition of the United States with two notable exceptions:
While only 13% of the U.S. population is Black, 21% of those who died from coronavirus are Black.3,4
While only 18% of the U.S. population is Hispanic, 21% of those who died from coronavirus are Hispanic.2,3
Several forces led to people of color being disproportionately affected. First, there is a higher incidence of underlying health conditions such as diabetes, heart disease and lung disease that are associated with about 90% of the hospitalizations for COVID-19.5
People of color also have experienced greater risk exposure since they were slightly more likely to be essential workers—representing 39% of the U.S. population but 45% of essential workers.6 For many, being an essential worker made social distancing impossible, since their role required close contact with the public...and often no paid sick days.
While data from the COVID-19 pandemic was already enough to spark a meaningful discussion about race and health equity, the death of George Floyd then intensified conversations about racism and its impact on health status.
Right now, few of us are likely doing as much as we could to address these issues. However, we must leverage this moment of consciousness to push us forward in affecting positive change. In exploring the greater context of these opportunities, let’s discuss what we mean by health equity, the rationale for change, pathways to achieving it and what you can do now as a leader. Ultimately, the intent is to explore the dynamics in order to shape a path for action. Simply, we can no longer say this is not our problem or our role to address—this is everyone’s problem—so we must decide if we will be architects and activists for change or whether we will simply be bystanders.
EXPLORING HEALTH EQUITY
As we begin our conversation, there is value to defining what we mean by health equity. Today in the United States, widespread differences in health status—such as illness, disability or mortality—are closely linked to race, ethnicity, socioeconomic status, gender, sexual identity and more. Inequity results in health disparities such as increased rates of heart disease, cancer, diabetes and asthma, as well as drug abuse and violence.8 The U.S. Department of Health and Human Services notes inequities are “unfair, unjust, avoidable, or unnecessary” conditions that can be “reduced or remedied.”9 So, simply, health inequity means select people in our country unnecessarily and consistently face greater health risks and experience poorer health because of their race, socioeconomic status or other identifiers.
Health inequity is largely fueled by consistent and avoidable differences in access to resources and support. So, it’s valuable to consider that a person’s health status is largely shaped by:
individual risk factors such as behavior or genetics
access to quality medical care
social determinants of health
Social determinants of health have the most influence on health status. In fact, 80% of a person’s health is shaped by social determinants of health rather than the work of health care organizations. Social determinants of health are driven by social, economic and environmental factors that shape the conditions in which a person is born, lives, works and plays. These differences are deeply intertwined with socioeconomic status, educational attainment and social power. They also reflect social needs such as access to:
Fresh, healthy, affordable foods
Safe, stable, affordable housing
Reliable transportation
Safe places to play
Social integration and support
Access to health care is also part of the social determinants of health. Key concerns are the lack of access to health care services and resources such as:
hospitals and clinics
physicians and clinicians
culturally competent care
medical technology
prescription therapies and medications
Therefore, for many, social determinants of health are the visible face of structural racism. Structural racism is the most complex and entrenched form of racism. It is not about our individual attitudes, intentions and behaviors toward others. It is about macrolevel systems such as institutions, ideologies, culture, law, policy and processes that interact with one another to reinforce inequality.10 Structural racism leads to a “systematic disadvantage of one social group compared to other groups with whom they coexist.”11
Clearly, there is a value chain here. Since social determinants drive 80% of health status, health organizations must tackle the root causes of poor health in the intertwined issues of structural racism and social determinants of health to truly elevate the health status. While health organizations have discussed the importance of moving upstream to address social determinants of health and social needs for more than a decade, most organizations have never substantively moved from discussion to action or have created fractured approaches— largely because of resource constraints. While impacting deeply embedded social, economic, environmental and structural factors that create health disparities and inequity is daunting, change must start somewhere...and fostering collective action through philanthropy and partners will emerge as a vital, new imperative.
RATIONALE FOR ADDRESSING HEALTH EQUITY
There are many reasons for health organizations to take a bold and proactive stance to address health equity. For example, it would align with a changing perception of the role of health care, elevate overall health status, achieve significant economic benefits and support expectations for collaborative solutions. All these things validate the rightness of deepening our resolve in this space. So, let’s look at the rationale for action.
Changing Understanding of Health Care
Amplified conversations about addressing disparities comes at a time when health organizations are already reconsidering and reimagining their roles. While hospitals and health systems have traditionally treated illness and injury, hospitals now face an expanding vision of their role that encompasses prevention and addresses social needs. Health care’s new measure of mission fulfillment is referred to in a lot of ways: community health impact, population health, addressing social determinants of health and more; however, the singular focus is to proactively elevate individual and community health status. A new article from McKinsey Global Institute articulates the opportunity well: “We must pay as much attention to health as we do to illness...The real question is how to shift from a focus on disease care to a mindset of disease prevention and health promotion while ensuring effective acute care services and sufficient capacity to deal with surges and crises. This shift involves ensuring that health promotion, preventive care, and early intervention are prioritized on a par with disease care and treatment.”12
Elevating Overall Health Status
As health organizations expand their vision of their roles, improving the health of individuals and communities remains at the heart of their mission. With that in mind, there are significant vulnerabilities in our current system if we fail to address health equity. Today, multiple sources rank overall health status and health care in the U.S. below that of dozens of other countries based on measures including mortality, disease burden, treatment outcomes and more. One of the obstacles frequently cited to explain the United States’ low rankings is the consistency and severity of health disparities.
KFF notes, “Disparities in health and health care not only affect the groups facing disparities, but also limit overall gains in quality of care and health for the broader population and result in unnecessary costs.”13