Expert Perspectives: Eliminating Health Disparities

Georges C. Benjamin, MD, MACP, FACP (E), FNAPA

The COVID-19 pandemic caused by SARS-CoV-2 revealed the  presence of health disparities to our entire nation. COVID-19 infection, hospitalization and death rates have been higher among American Indian and Alaska Native, African American and Hispanic people than non-Hispanic White people, starkly demonstrating how existing disparities can compound the infectious health risk of specific populations and the need for early programmatic focus on these populations to mitigate the perpetuation of unequal health outcomes.

The presence of such tragic health disparities in communities of color is not a new phenomenon. In 1865 President Abraham Lincoln strongly encouraged the U.S. Congress to create the Freedmen’s Bureau to address the many social and health needs of newly freed slaves and low-income Whites after the Civil War. Later in 1906, W.E.B. Du Bois published the monograph “The Health and Physique of the American Negro,” ¹ which documented the health disparities of African Americans and the critical role social determinants played in these inequities. Years later, Secretary of Health Margaret Heckler charged Dr. Thomas E. Malone and members of the U.S. Department of Health and Human Services Secretary’s Task Force on Black and Minority Health² to explore the issues surrounding racial and ethnic disparities in health. This landmark report released in 1985 noted the need to improve data collection among Hispanic people, American Indian and Alaska Native people as well as Asian American people because national health data was inadequate. The report documented that over 60,000 excess deaths occurred annually among racial and ethnic minority groups, and 80% were caused by only six causes of death: cancer; cardiovascular disease and stroke; diabetes; chemical dependency; homicide and unintentional injuries; and infant mortality. These diseases remain among the leading causes of death and disability for ethnic minority groups, and while the incidence of many of these diseases has decreased over time, the disparities between them and non-Hispanic White people has not substantially narrowed.

Four factors often attributed to causing these health disparities are: differences in access to health services including health insurance coverage; differences in the quality of care received in the health care and public health settings; differences in health-seeking behavior by individuals and populations; and differences driven by the social determinants of health. These factors work both independently and collectively, resulting in worse health outcomes for people in some racial and ethnic minority groups.

During the COVID-19 pandemic, health inequities have been driven by enhanced exposure because people in racial and ethnic minority groups tend to be more highly represented in occupations where they are unable to work from home, thereby making them more likely to be exposed to others infected with SARS-CoV-2. When infected, they were also less likely to get tested because of the initial locations of the testing sites – and more likely to be unable to take time off from work for testing or medical care because of a lack of paid sick leave. Underlying disparities in health status for diseases like diabetes, hypertension, cardiovascular and lung disease made them more susceptible to severe COVID-19, resulting in higher hospitalization and death rates. Social conditions, like multiple generational households and smaller homes, meant many were more likely to live in dwellings where it was harder to isolate after diagnosis or quarantine following a known exposure, resulting in higher household spread.  Disinformation and misinformation have indeed been rampant throughout our society throughout the pandemic, but particularly troubling have been the malicious efforts to specifically target ethnic minorities to dissuade them from getting tested and now vaccinated. These messages have resulted in differences in health-seeking behavior, which still hamper the vaccination effort today.

So where do public health and agencies like the CDC fit in efforts to eliminate health inequities? The three core functions of public health are our roadmap for this. We must make assessment a priority by first collecting adequate demographic data and data on social determinants of health so we can understand who is at risk and mitigate that risk. This means requiring that this demographic data be collected by race and ethnicity and then ensuring the data systems, tools, and training are in place to accomplish this. The data must not only be accurate, but also validated, analyzed, and publicly available in a timely way to allow for a transparent response to what we discover. We must then develop policy and programs to address what we find, followed by the assurance that such programs are properly conducted, with evaluation mechanisms to measure their impact.

We must address the social determinants of health that have the capacity to both enhance our health as well as serve as a barrier to equal health. Dealing with the reasons people seek health differently is essential, especially when some of the reasons are driven by racism and discrimination that have made people lose trust in the health system. Finally, ensuring we have a health system with everyone in and no one out is also key to solving this problem. The Affordable Care Act stands as a step forward to achieving this goal. But affordable health insurance is not enough — we also must ensure we have enough culturally competent health care providers and accessible facilities in all communities.

Eliminating health disparities is an issue whose time is long past due. The time to do it is now!