Navigating to Kidney Health Equity

In recent years, all health organizations and institutions have agreed, in principle, that reaching health equity is important. And yet, in practice, achieving this goal is like planning a journey to a destination we are unsure exists. Typically, the goals and objectives that guide programmatic, funding, and policy efforts in the United States (e.g., Healthy People 2030) include specific, measurable, acceptable, realistic, time-bound objectives, but this is not the case for reaching health equity. What health equity means in practice remains ill defined and unclear, making it even more challenging to achieve equity in kidney health outcomes. In this paper, we discuss three key questions to help focus practice, policy, and research to reach kidney health equity: (1) How do we chart our course? (2) How do we pack and prepare for the journey? (3) Who needs to join us in the journey to kidney health equity to give us the greatest chance of reaching our destination?

Charting our Course

In planning our expedition to kidney health equity, we have to take stock of what we know about research and practice that will guide how we embark on our journey.^1,2 We also have to mobilize and bolster the political will to not just begin the journey, but to sustain the commitment to reaching our destination. See Table 1 for an initial list of metrics that characterize our destination of kidney health equity. Charting the course to guide our journey has to be rooted in a culture of commitment and accountability to the principles of fairness and justice that are the foundational structures that will guide us to our destination.

Table 1. - Kidney health equity societal checklist

Checklist	Metric
✓	All have optimal kidney health.
✓	The society is structured so that all have equal opportunities to have optimal kidney health.
✓	The society is structured so that all have equal opportunities to have optimal kidney health care (e.g., equitable access to early diagnosis and intervention; kidney transplant; dialysis, particularly access to home dialysis modalities; and equitable dialysis allocation involving the development of antiracist reimbursement policies in ESKD 3 ).
✓	Kidney disease epidemiologic metrics are not clinically or statistically significantly different by socially meaningful categories (e.g., race, ethnicity, sex, sexual orientation, gender identity, residence), or any combination of those categories.
✓	The cultural norm in society is that clinically or statistically significant differences in kidney health outcomes are modifiable, unacceptable, and a financial priority to eliminate.
✓	The society has created, adequately invested in, put in place, and committed to keeping in place processes to monitor epidemiologic patterns and determinants of kidney health and kidney disease on a regular basis (e.g., annually).
✓	The society has made and continues to be committed to eliminating inequities in epidemiologic patterns and determinants of kidney health or kidney disease within a fairly short timeframe (e.g., within 2 years).
✓	The health care, public health, and other sectors of society prioritize kidney health as an important metric of their effectiveness.
✓	The decision-making bodies designing the metrics, reviewing the data, and deciding how to intervene to maintain kidney health equity include equal power and influence of the following groups: (1) those who have been diagnosed with a kidney disease; (2) those are at significant risk to develop a kidney disease; (3) those who are allies or loved ones of someone who has been diagnosed with kidney disease; (4) professionals with expertise outside of nephrology; and (5) nephrologists (and other kidney disease practice experts) and kidney disease research experts.
✓	The health care, public health, and other sectors of society are structured so that organizational, institutional, or sectoral resources are marshalled to promote and sustain kidney health equity.

The challenge we face is not simply one of innovation. We have to provide organizations and institutions the tools to plan for the best ways to acquire, mobilize, and utilize the resources necessary to support the expedition ahead. We are trying to reach a destination and create a community that can live and thrive once there. Whether our destination is a different location or the result of how we reimagine, renovate, and create the context is immaterial. The point is to be clear about where we are going and how we can get there.

Our expedition should begin with fairly and equitably implementing what we know works to improve health (e.g., supporting the American Society of Nephrology’s “We’re United 4 Kidney Health” campaign). Implementing practices, processes, programs, and policies from our evidence base should be done in a manner that takes into consideration the differential access to health promoting resources and differential exposure to health harming conditions that exist by markers of structural advantage or disadvantage such as race and ethnicity. Further, we need to redirect our science, publications, funding, and other resources from novel discoveries and descriptive epidemiology to implementing evidence-based processes, programs, and policies with explicit and measurable objectives for achieving fair and just opportunities to have equal health outcomes. Currently, none of the strategic plans of federal or foundation initiatives aiming to address health disparities or to achieve kidney health equity prioritize implementing programmatic nor policy strategies in a fair and just manner.² We need to expand our research efforts beyond assessing the magnitude of kidney disease inequities to focus on the effect of policies on kidney disease inequities and kidney health,³ and to champion policies and practices that eliminate the root causes of inequities.⁴

Preparing for the Journey

Kidney health equity and equity in overall health and wellbeing are enmeshed. The health of the kidney cannot be separated from that of the body or population in which it exists. Thus, the ubiquity of other chronic health conditions and contexts that are stress promoting and do not make healthy choices easy highlights the need ensure access to high-quality care is available to all and to prioritize the whole person over a disease-specific approach.^5,6 For nephrologists, grappling with the full range of determinants that shape their patients’ adherence, health behaviors, and health outcomes may lead to more patient satisfaction and better clinical outcomes. We need patience and humility to acknowledge that even when providers recognize the economic and social factors that are adversely affecting their patients’ health many are unsure how they can intervene.⁷ Nonetheless, planning to reach kidney health equity may raise challenges for specialists including nephrologists such as, how do I use my clinical tools and expertise in nephrology on the journey to health equity? Fundamentally, that is the wrong question. Excellence in kidney care is necessary to reach kidney health equity; it is simply insufficient. Within the health care system, we have already learned that strategies such as eliminating race-based medicine, enhancing workforce diversity, and equitably disseminating technological advances are useful tools.⁵ We also know that promoting strategies to ensure equity in health care access and quality—such as using clinical decision aids to address social determinants of health—are important tools to ameliorate poor health and reduce mortality rates.⁷ To complement the expertise of the nephrology community, it is critical to add other types of expertise to help prepare us for the journey.

Creating our Crew

The crew that we assemble for this expedition should bring lived experiences and diverse disciplinary expertise that complements our knowledge of kidney disease and health. Patient-centered communication and shared decision-making efforts to promote kidney health equity should begin with understanding how kidney and overall health fit into the priorities of peoples’ lives. The social and cultural assets that sustain kidney patients, their loved ones, advocates, and community partners as they face structural racism and other forms of structural violence are critical perspectives to have on our expedition.^1,8 Perhaps counterintuitively, it is likely the people who know the most about the destination we seek are likely the ones with the most lived experience and the least technical expertise. People with kidney disease, their loved ones, and their community partners recognize that kidney health and health overall are instrumental goals, ones that are necessary yet insufficient to give their lives meaning, purpose, and fulfillment.^8,9

In addition to patients with kidney disease, their loved ones, advocates, and community partners, our crew should include people from other areas of medicine and professionals from the social sciences, humanities, law, policy, and public health fields. Scholars with expertise in medical humanities, social sciences, and other disciplinary areas will help us see clearly the sociohistorical constraints and entrenched barriers that impede our ability to see our destination or the waypoints that help us know we are on the right path. The expertise of patients, loved ones, advocates, community partners, and experts from other disciplinary areas will be essential to creating strategies to mitigate or eliminate the dynamic and wicked structural obstacles in our way.

Kidney health equity is not simply a moral imperative, but a necessity to reduce the drain on our health care system, health care providers, overall economy, and collective wellbeing that health inequities represent. The tools necessary to plan our journey and navigate to our destination are not within the existing clinical tools of most nephrologists, but skilled nephrologists are certainly part of the crew to guide us to our destination.¹⁰ We need to be clear about our destination, what it will take to get there, why we seek to go, and what we need to do to thrive once there. We cannot get there alone.

Disclosures

All authors have nothing to disclose.

Funding

This work is supported by National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases awards K23DK114566 and R03DK129626 (to E. M. Umeukeje).