According to the World Health Organization, equity is “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.”1 Addressing the root causes of health inequity requires synergistic partnerships, comprehensive policy development, innovative programming, multisectoral investments, and a transformation in how public health practitioners think about, talk about, and tackle health disparities.
Historically, public health practitioners and health care providers have focused on health disparities in access to health care and services and, more recently, social determinants of health, which are widely recognized as major contributors to health inequity. It is just as important, however, for public health leaders to address other issues, including discriminatory public policies in areas such as income, housing, and transportation and societal concerns such as racism and privilege. Health equity may be among the hardest achievements ever attempted by public health. But it can be accomplished. As public health leaders look beyond access to care and health disparities, they must address how race-based privilege and institutional racism affect health equity, how health equity can be integrated across all public policies, how they can find and work with partners to strengthen existing infrastructure in ways that help achieve health equity, and how they, as leaders, can facilitate change.
Rooted in subtlety and complexity, race-based privilege and institutional racism have a devastating, lasting impact on health equity, resulting in disparities that begin before birth and can last for generations. The Life Course Perspective2 challenges the traditional approach to addressing health in stages by instead recommending an integrated continuum approach, highlighting the importance of using health equity to lead and guide the work around achieving optimal health for all.
Deeply ingrained structural and systemic policies also affect housing, transportation, education, job creation, access to food, and environmental health. The housing policy introduced by the creation of the Federal Housing Administration (1934-1968), also known as “redlining,” explicitly refused to back loans to black people or anyone who lived near them.3 Today, redlining is illegal but continues to take place. Within the past few years, several financial institutions have settled with the justice department for redlining.4 The devastating effects of redlining still persist through segregated neighborhoods resulting in lower property value, which means less taxes and substandard government services, including education. With low land value and substandard education as a result of redlining, businesses found nonwhite neighborhoods unattractive.5 While laws such as the Community Reinvestment Act (12 USC 2091), originally enacted in 1977, were passed to counteract years of segregation and isolation, society is still far from undoing the damage of the policy, which lead to less access to capital and accumulation of wealth over generations for affected families.6
Privilege and Institutional Racism
Privilege is not only thought of in terms of wealth but has also been redefined by social scientists and is presently used to describe “a group of people who receive unearned benefits, whose perspective is shaped by the fruits of those unearned benefits.”7 Privilege may be associated with race. Peggy McIntosh wrote an essay listing 50 “Daily Effects of White Privilege,” where examples include “I can go shopping alone most of the time, pretty well assured that I will not be followed or harassed,” and “Whether I use checks, credit cards or cash, I can count on my skin color not to work against the appearance of financial reliability.”8
Privilege plays a key role in perpetuating health inequities, but it undoubtedly has an equal partner in institutional racism. The sociologist Earl Babbie defines institutional racism as “an action which is not directly discriminatory but has a discriminatory effect, whether intended or not.”9 In the health care setting, institutional racism manifests itself through barriers in access to providers and services, discriminatory policies and practices such as a lack of continuity of care, and a lack of language and culturally competent health care.10 Race-based privilege and institutional racism are ubiquitous; achieving health equity and tackling privilege and institutional racism will require innovation, patience, leadership, and courage that can only come from a collective effort.
The Association of State and Territorial Health Officials (ASTHO) recognizes the importance of integrating equity into internal policies, incorporating it into the fabric of the organization, and promoting it externally to its members and partners. In 2010 and 2013,11 ASTHO worked collaboratively with a diverse group of stakeholders to update the Health Equity Strategic Map, a roadmap used by the organization to infuse health equity broadly across many different areas of programmatic work.12 The central challenge in the Health Equity Strategic Map is to “Mobilize Leadership to Achieve Health Equity” by (1) fostering societal understanding and the will to achieve health equity, (2) leveraging and engaging broad public/private partners in health equity solutions, (3) leveraging existing and new funding for health equity, and (4) strengthening organizational effectiveness in support of health equity. The strategic map demonstrates the overarching emphasis and integration of health equity across all of the work ASTHO does.
Each year, the ASTHO President selects a topic or area to champion among his or her colleagues known as the ASTHO President's Challenge. The 2011 ASTHO President's Challenge, issued by John Auerbach, then the commissioner of the Massachusetts Department of Public Health, challenged other state health officials to develop and implement strategies to promote health equity and reduce disparities. The 2012 ASTHO President's Challenge on Healthy Babies, issued by Dr David Lakey, then the commissioner of Texas State Health Services, built on the previous year's challenge by incorporating efforts to eliminate disparities in infant mortality and prematurity rates. Current ASTHO President Dr Edward Ehlinger, commissioner of the Minnesota Department of Health, has launched the 2016 President's Challenge on the Triple Aim of Health Equity: Advancing Health Equity by Creating Optimal Health for All. His framework encompasses 3 key strategies: (1) expanding the understanding about what creates health, (2) strengthening the capacity of communities to create their own healthy future, and (3) implementing a Health in All Policies approach with health equity as the goal. Through this President's Challenge, ASTHO will build on previous challenges by strengthening cross-sectoral collaborations to mobilize all levels of leadership to advance health equity.
This issue of the Journal of Public Health Management & Practice features 3 articles from state health agencies in California, Minnesota, and Oklahoma. While each state has unique health equity challenges, it is notable that all 3 are working to achieve their goals by emphasizing the importance of collaborative governance and cross-sectoral partnership models. Synergies also exist among the states in their efforts to adopt, create, or influence policy to ensure that future generations have an equal chance at achieving health equity.
Systematic changes are necessary to address health equity. Society needs policies and structures that reduce the structural inequality of income, housing, and transportation; rewire the way public health practitioners think about health, and address the root causes of health inequity; and develop a framework around health equity that reflects social and environmental justice. These changes can be achieved by promoting public health and population health approaches to achieving health equity, learning to consider an individual's life and experiences as a determinant of future health outcomes, raising awareness of the impact that race-based privilege and institutional racism have on health outcomes, and developing a comprehensive framework that looks at optimal health for all as an achievable goal. ASTHO is committed to achieving health equity. As this new challenge unfolds, ASTHO will work with new and existing stakeholders and listen to all points of view in order to forge a new path to eliminate health disparities and achieve health equity and optimal health for all.
7. Sehgal P. How privilege became a provocation. The New York Times. http://nyti.ms/1K40Ncu
. Published 2014. Accessed September 2015.
8. McIntosh P. White privilege: unpacking the invisible knapsack. This essay is excerpted from “White Privilege and Male Privilege: A Personal Account of Coming to See Correspondences Through Work in Women's Studies.” http://amptoons.com/blog/files/mcintosh.html
. Published 1988. Accessed September 2015.