If you work in public health, a foundational part of your job is health equity. Simply stated, until and unless we address health equity, we will not be a healthy nation. The World Health Organization eloquently and succinctly provides the following aim for health: “The objective of good health is ... twofold: the best attainable average level—goodness—and the smallest feasible differences among individuals and groups—fairness.”1 ASTHO's 2013–2015 Strategic Map aligns well with the notion of goodness and fairness in its central objective: “Strengthen the effectiveness, value, and relevance of state and territorial public health in promoting health equity and improving health outcomes.”2
Health inequities exist among groups based on gender, sexual orientation, race, ethnicity, education, income, disability, and geographic location. In addition, the burden of health inequities constitutes a huge financial and social cost to our nation in terms of the quality and quantity of life. The Department of Health and Human Services acknowledged the central importance of addressing health inequities and disparities to achieve overall improved health when it established “a renewed focus on identifying, measuring, tracking, and reducing health disparities through a determinants of health approach” as one of two overarching goals of Healthy People 2020, the national blueprint for public health.3 This focus has been further strengthened by the National Prevention Strategy, which established “Elimination of Health Disparities” as a strategic direction.4 In addition, ASTHO has been actively involved in supporting the development of the National Partnership for Action to End Health Disparities. Our members also use the Department of Health and Human Services “National Stakeholder Strategy for Achieving Health Equity,” which creates a flexible roadmap for public and private sector partnerships to work together on health equity initiatives and programs. Goals of the National Stakeholder Strategy include awareness of health inequities; leadership; health system and life experience; cultural and linguistic competency; and data, evaluation, and research.5
Significant disparities exist in key health indicators (such as infant mortality rates, life expectancy, and rates of preventable disease), key risk factors (such as smoking rates, access to care, nutrition, and exercise), and the social determinants of health (such as poverty, inadequate housing, and unsafe working conditions). The effects of racism, whether institutional or internalized, also have profound health effects. Health disparities that have their roots in social determinants of health are referred to as health inequities and are a reflection of the persistent inequities that exist in American society. Data clearly show that there are serious health disparities by race, ethnicity, socioeconomic class, geographical location, education, and other social determinants of health.
* Infant mortality among African Americans in 2007 occurred at a rate of 13.3 deaths per 1000 live births, which is more than twice the national average of 5.6 deaths per 1000 live births.6
* Between 2003 and 2006, the combined costs of health inequalities and premature death in the United States were $1.24 trillion.7
* Eliminating health inequalities for minorities would have reduced indirect costs associated with illness and premature death by more than $1 trillion between 2003 and 2006.7
State and territorial health officials are in a unique position to raise awareness and lead state and local action to address health disparities. ASTHO recognizes that to make progress in improving the health of all populations and achieving greater health equity, states must have access to information on effective practices as well as resources to assist in the implementation of effective public health policies and programs. In addition, state public health capacity to address minority health and health equity issues is critical to achieving health equity.
States Make Health Equity a Priority
Georgia was consistently near the bottom of state rankings, showing the worst infant mortality rates. To develop strategies to improve this figure, the Georgia Department of Public Health developed a creative approach to ascertain where to focus its efforts. Rather than using data from counties or zip codes, Georgia overlaid the state with 1 × 1-mile grid to look at infant mortality statistics. It found that often a cluster indicating a location of high infant mortality would intersect 2, 3, or even 4 counties. Using zip code or county analysis would likely not have highlighted the location as an area to focus on. Georgia used the information both to assess whether the modifiable risk factors for infant mortality are the same for the entire state and to develop target interventions for the areas of highest need.8
Maryland Secretary of Health and Mental Hygiene Joshua M. Sharfstein, MD, presented Baltimore's successful Safe Sleep campaign in a presentation at ASTHO's 2011 Annual Meeting. He noted that an effort to reduce infant mortality had been successful in reducing the rate. But when they initially examined the numbers, they discovered that almost all the reduction had come from white households. The city and state had to redouble, and redirect, their efforts to ensure that positive health outcomes reached across racial and ethnic lines. By 2010, Maryland had reduced the black infant mortality rate by 13%, from 13.6% to 11.8%, and the overall infant mortality rate decreased from 7.2% to 6.7%. By doing so, they achieved both goodness and fairness.
The Ohio Department of Health initiated a policy to integrate health equity into its public health program grants and requests for proposals. All applicants applying for money from the Ohio Department of Health are required to explain the extent to which health inequities are evident within the health focus of the application, identify specific groups that experience a disproportionate burden of the health condition, demonstrate how proposed activities address health inequities, and include a scoring requirement that must include points for the inclusion of the health equity activities. This also includes identifying social or environmental conditions that are the root causes of health inequities.
ASTHO's Organizational Efforts
ASTHO favors the term “health equity” over “health disparity” because it is aspirational; it is something to strive toward. After all, Martin Luther King shared with us his dream to which we can all aspire. Where health disparity describes a deficit, health equity is about taking action to reach a goal. For many years, ASTHO has had a strategic mapping process to guide its priorities and work. In strategic maps from 2000 to 2006, the term “health equity” or any of its synonyms did not appear on the map. From 2007 to 2012, “Promote Equity in Health” was included as a crosscutting objective spanning all of our work. Our new strategic map, to guide us from 2013 to 2015, has elevated “health equity” to the central strategic challenge for our organization. This progression was mirrored in the work that ASTHO has done on health equity.
ASTHO convened an expert panel of leaders and practitioners in health equity from the federal government, state public health, and academia to develop a specific health equity strategic map to guide our work. An important element of the health equity strategic map is to “establish policy to require focus on health equity in all funding opportunities.” To achieve this goal, ASTHO's internal Health Equity Workgroup, which consists of representatives from all program areas at ASTHO, led the organizational effort to integrate health equity into the public health program areas' grants and requests for proposals. A health equity glossary of terms shared with grant and proposal writing staff is just one example of how we encouraged the inclusion of health equity in our program of work. Of the 40 ASTHO workplans submitted for the 2012 Centers for Disease Control and Prevention cooperative agreement, 12 (30%) contained health equity terms. Of the 44 workplans submitted for the 2013 Centers for Disease Control and Prevention cooperative agreement, 26 (59%) contained health equity terms. While we are making progress, we have much further to go before all programs clearly establish health equity priorities.
In 2011, John Auerbach, who was ASTHO President and the Massachusetts Commissioner of Public Health, challenged his state health official colleagues to make health equity a central focus within their health agencies by issuing the 2011 ASTHO President's Challenge on Health Equity. States developed and shared programs that made a measurable impact on health disparities; ASTHO held high-level meetings with federal agencies and other public health organizations to raise awareness and rally support behind the challenge; and health equity was the focus of several sessions at the 2011 ASTHO Annual Meeting. Importantly, the challenge created momentum. The well-attended ASTHO/American Public Health Association Health Equity Forums, which have been held at the American Public Health Association Annual Meeting each year since 2010, are a great example. ASTHO brought together leaders of national importance in a moderated panel discussion on what state health agencies and leaders can do to implement and achieve health equity.
Another example of this momentum is the ASTHO Affiliate Council Health Equity Initiative. ASTHO has a formal relationship with 20 national organizations. These affiliates include National Association of State Offices of Minority Health, Association of Maternal Child Health Programs, National Alliance for State and Territorial AIDS Directors, and the National Association of Chronic Disease Directors, among others. ASTHO and the Affiliate Council have established “health equity” as a strategic priority to collaborate on across the organizations.
This group has determined action items to promote health equity among their own members. The Affiliate Health Equity Subcommittee meets monthly to discuss affiliate involvement in health equity issues. Some of the products from this subcommittee include a survey report that assessed the needs for health equity tools and resources among public health care professionals in a joint position statement on health equity, an affiliate health equity resource guide, and recommendations to the Public Health Accreditation Board on how to more explicitly include health equity into their revised standards and measures.
A third example of the momentum is that it led to the successful 2012 Healthy Babies President's Challenge, issued by then-ASTHO President David Lakey, MD, the commissioner of the Texas Department of State Health Services. This initiative focused on a critical area of health equity: infant mortality. Forty-nine states, as well as Washington, District of Columbia, and Puerto Rico, rose to the challenge and publicly pledged to reduce preterm births by 8%.
As leaders in public health, we must work to maintain this momentum. After all, goodness and fairness do not sound like audacious goals. Sending a person to the moon within 10 years—that was an audacious goal. We did that more than 40 years ago. Health equity remains aspirational, but if we make it a central tenet of the work of public health and include it in all our projects, programs, and services, we can achieve it.