Chapter 1: Health Equity
The World Health Organization defines equity as “…the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification.” The Department of Health and Human Services Office of Minority Health takes it a step further to explore health equity, “…attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”
The quest for health equity requires an intersection of public health and social justice. It requires understanding the difference of health disparities (a difference in comparable health outcomes) compared to health inequities (a difference in comparable health outcomes that is rooted in unfairness or injustice), and putting strategies into practice to prevent the continuation of inequity. For example, the increased rate of HIV transmission through cisgender male-to-male sexual contact versus cisgender heterosexual contact is a health disparity. But, the fact that Black men who have sex with men have higher rates of HIV infection compared to other races and ethnicities engaging in the same sexual behavior is a health inequity. This is due to the disproportionate effect of HIV on Black Americans being driven by: institutional racism, systemic poverty, lack of access to culturally relevant health care, smaller sexual networks, unknown HIV status, homophobia, provider bias, and stigma.
Why do health inequities exist? It boils down to how social determinants of health, “environmental conditions (where people are born, live, learn, work play, worship, age) affect quality of life.” This includes physical settings (neighborhood, workplace, school, etc.) and the social engagement and sense of security when in these settings. Resources that impact environmental conditions include access to: safe and affordable housing, education, public safety, access to healthy foods, transportation, local emergency/health services, freedom from police brutality, and environments free of life-threatening toxins. The relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health. To achieve health equity, we must work to allay stigma and implicit biases at the individual, community, and health department or systemic level.
How Racism Makes Us Sick | TEDMED 2016
In this talk, Dr. David Williams shows the scale he developed to measure the impact of discrimination on well-being, going beyond traditional measures like income and education to reveal how factors like implicit bias, residential racial segregation and negative stereotypes create and sustain inequality. 17 min, 28 sec
Why Your Doctor Should Care about Social Justice | TEDMED 2015
In public health, we often hear the term “hard to reach populations.” This idea places the onus on the population instead of responding to research indicating that the ownership is on public health practitioners to remedy or inability to offer culturally responsive and accessible services that prioritize seating the most impacted populations in positions of power. It is our role to engage providers in conversations, trainings, and practices to dismantle structural barriers that impact health equity. 13 min, 50 sec
Health Department Examples
Iowa
The Iowa Department of Public Health (IDPH) has made strides to reframe HIV prevention and care services to reflect the disproportionately high burden of developmental trauma (i.e., adverse childhood experiences (ACEs) among PLWH. These efforts include: the establishment of the Trauma Informed Leadership Workgroup, a collective of health department staff across programs; hiring a Trauma Informed Prevention and Care Coordinator to lead, assess, and expand on trauma informed capacity-building statewide; and sponsoring Trauma Informed Excellence (TIE) trainings among clinical and non-clinical providers. Iowa's Trauma Leadership Workgroup is an interdepartmental team dedicated to breaking down silos and promoting trauma informed care across disciplines. As stated by an Iowa services provider: “A trauma informed approach to my work helps me see my clients as humans who are in need of compassion and assistance when it can be so easy to instead be overwhelmed by the volume of what needs to be done.”
Louisiana
The Louisiana Department of Health Office of Public Health produced a five-year State Health Improvement Plan (SHIP) that outlined priorities and strategies for health status and public health system improvement. The SHIP also addressed supporting behavioral health, promoting healthy lifestyles, assuring access to healthcare and promoting economic development. The plan was produced by a team of public, private and multi-sector stakeholders. The SHIP included plans to support the Office of Minority Health in state initiatives and conduct the Undoing Racism training through the People’s Institute for Survival and Beyond with staff and partners.
New Jersey
In response to the structural and social barriers young, gay, bisexual and other men who have sex with men face, the New Jersey Department of Health Division of HIV, STD and TB Services (DHSTS) developed a supportive transitional housing project, funded through Ryan White Part B rebates, to co-locate needed medical case management, psychosocial support services, independent living readiness, and more in a transitional housing program in partnership with the AIDS Resource Foundation for Children. From 2015 to present, 54 residents have been inducted into the program. Of those 54, 30 have stayed longer than three months with 90% achieving viral suppression, 100% with access to treatment, and no missed HIV medical visits in the last six months.
Washington
The Point Defiance AIDS Project Care Coordination Initiative in Washington State provides care coordination services to address housing and treatment access needs for participants of Syringe Service Programs (SSPs). The program works to reduce stigma and impact social determinants of health through a harm reduction approach, ultimately increasing participants’ ability to meet their own HIV/HCV care goals. During a four-month period, all participants were linked to housing and most entered drug treatment through care coordination.
Key Resources
Creating the Healthiest Nation: Advancing Health Equity | APHA 3 pages
Trauma-Informed Approaches Toolkit | NASTAD 23 pages
Achieving Health Equity: Tools for a National Campaign Against Racism | UC Berkley 1hr, 16min
Additional Resources
Undoing Racism Training: The People’s Institute for Survival and Beyond 1 min, 13 sec
THRIVE: Tools for Health & Resilience in Vulnerable Environments | Prevention Institute website
Reducing Racial Inequities in Health: Using What We Already Know to Take Action | NCBI
Check Your Understanding
What is the difference between health disparity and health inequity?
Health disparities acknowledge differences in health outcomes, whereas health inequities underscore the negative social factors, which are usually preventable, that influence these differences.
Name the term that describes, “environmental conditions (where people are born, live, learn, work play, worship, age) that affect quality of life.”
Social determinants of health.
How do social factors hinder efforts to achieve health equity?
According to the CDC, social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities.
Complete the sentence: To achieve health equity, we must work to eliminate stigma and implicit biases at the individual, community, and __________ level.
Health department or systemic.