Abstract
Decades of surveillance and research in the United States have documented health disparities in morbidity and mortality, particularly among racial/ethnic minority groups and those of lower socioeconomic status. Moreover, it is estimated that from 2003 to 2006 the combined costs of health inequities and premature deaths in the United States totaled $1.24 trillion and that elimination of health disparities among racial/ethnic minorities would have reduced these costs, including direct medical care, by $229.4 billion. In response to health inequities, national initiatives have been undertaken such as Healthy People 2020 and the National Partnership for Action to End Health Disparities. Despite Healthy People goals and objectives over several decades and modest reductions in health disparities in the United States, there are still persistent and pervasive disparities. Thus, more intentional, comprehensive, system-oriented, and coordinated strategies should be employed to achieve health equity in the United States. The action items presented in this policy statement call on national, state, and local governments, as well as nonprofit and philanthropic organizations and individuals, to implement policies, practices, surveillance, and research that include a health equity lens and framework across all sectors of society such that everyone can live a long life in optimal health.
Relationship to Existing APHA Policy Statements
The following are some relevant APHA policies that are more narrowly focused on individual social determinants of health and health disparities.
Problem Statement
A major public health problem in the United States is that a baby born today is expected to have a shorter life span and live in poorer health than a baby born in other high-income countries.[1] Likely explanations for babies in the United States experiencing a poorer quality of life and dying earlier are that, relative to other high-income, democratic countries, the United States lacks organized and coordinated health and social systems and does not invest as many of its resources in social services. These circumstances translate to limited access to primary care, a larger uninsured population, increases in certain health risk behaviors (drug abuse and firearm violence), a greater population in poverty, less quality education of children, and less investment in safety net social programs. Furthermore, an outcome of these circumstances for U.S. babies during their life spans is that their health status varies by race/ethnicity; gender; income; education; cognitive, sensory, or physical disability; sexual orientation or gender identity; and place of residence (geography).[2–4]
There have been efforts at the community, state, and national levels to address these “unnatural” health differences by population and place across the United States. National initiatives have created measurable goals and objectives for the nation to monitor health outcomes and determinants of health. Healthy People, a science-based, 10-year health agenda, has measured national health promotion and disease prevention progress since 1979, and more recently is measuring not only health outcomes and risk behaviors but also the social determinants of health for the decade from 2010 to 2020. Currently, plans are under way for measuring health outcomes and determinants for 2020 to 2030.[2–4] Eliminating health disparities and achieving health equity such that everyone has optimal health (well-being) remains a foundational principle that guides the development of Healthy People 2030.[4] The purpose of Healthy People 2020 is to engage communities and every sector of society to act in improving health across the United States. The vision of Healthy People is that its goals and objectives in communities across the nation will be applied through engaging multiple sectors to take action as described in the National Academy of Medicine’s report Communities in Action: Pathways to Health Equity.[5] This report highlights the role of communities in driving action, policy, programs, or laws to promote health equity in communities. Partnerships between governments at every level and nongovernmental organizations (including not-for-profit organizations, foundations, and the private sector) are also envisioned through active participation of the entire nation working locally to implement effective policies and programs across all sectors in society.
The goals of Healthy People 2020 include achievement of health equity and creation of social and physical environments that promote good health for all.[2,3] Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people.”[2,6,7] Moreover, “[a]chieving 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 health care disparities.”[4,8] Other definitions of health equity, for example the definition offered by Dr. Camara Jones (APHA past president), posit that health equity is the assurance that conditions for optimal health are available for all people, based on the premise that all people are valued equally and injustice is both recognized and rectified.[9]
To assess health equity, a major measure is elimination of health disparities.[1] Healthy People 2020 defines health disparities as “a particular type of health difference that is closely linked with social, economic, and environmental disadvantage.”[1] As such, health disparities are rooted in sociopolitical and economic history. Health disparities adversely affect populations that have systematically experienced greater obstacles to health based on their race or ethnicity, religion, socioeconomic status, gender, age, mental health, disability status, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.[3]
Despite Healthy People goals and objectives over several decades,[7] and although there have been some health improvements, there are still persistent and pervasive health disparities in the United States. For example, pervasive disparities were reported in the 2015 midcourse review of national health progress toward Healthy People targets.[10] Only modest reductions were found in health disparities among the widespread health and social objectives examined.[10] Of the up to 492 trackable objectives by race/ethnicity, the Healthy People target was met or exceeded for 36.9% of non-Hispanic Whites, 27.2% of non-Hispanic African Americans, 34.8% of Hispanics, 26.6% of American Indians/Alaska Natives, 47.8% of Asians, and 43.9% of Native Hawaiians or other Pacific Islanders.[10]
Examples of persistent health disparities include infant mortality, all-cause mortality, and life expectancy. In fact, U.S. life expectancy in all populations dropped from 78.9 years in 2014 to 78.7 years in 2015 and 78.6 years in 2016.[11] It is well known that infant mortality, all-cause mortality, and life expectancy differ by race/ethnicity, and these disparities have been documented over the past three decades. Trends in infant mortality from the 1980s to 2016 show disparities for African American infants relative to White infants; infant mortality among African American infants, on average, continues to be twice as high as mortality among White infants.[12,13] These disparities have worsened over time despite declines in overall U.S. infant mortality,[12] and more recent adverse trends have been found among Puerto Rican, American Indian/Alaska Native, and Pacific Islander infants.[2] Likewise, disparities persist in all-cause mortality and life expectancy at birth for African Americans relative to Whites, even though there have been overall improvements in both indicators of health.[12] Furthermore, despite overall declines in cardiovascular disease (CVD) mortality, marked population and geographical inequities persist. A recent study showed a widening of the rural-urban disparity in CVD mortality, with mortality continuing to be higher in rural than urban communities.[14] From 1969 to 2011, the decline in CVD mortality was largest in New England and the Mid-Atlantic region and smallest in the Southeast and Southwestern regions. In 1969, the mortality differential in the Southeast relative to New England was 9%, and this differential increased to 48% in 2011.[14]
Other health outcomes such as obesity and diabetes, which have increased by epidemic proportions over the past few decades, show marked adverse disparities among African American and Hispanic populations in comparison with the White population at all time points during the 1980s to 2000s.[12] In addition, the legacy of slavery, racism, current oppression, and violence has impacted the mental health of African American populations. Several studies show that there is a relationship between self-reported experiences of racial discrimination and poor mental health among African Americans (as an example), including increased risk of depression, anxiety, substance use, and psychological distress.[15–17] Although the proportion of individuals receiving mental health treatment has increased, racial/ethnic disparities with respect to access to mental health treatment still persist among both children and adults.[18] In fact, this circumstance leads to members of racial/ethnic minority groups being less likely to achieve symptom remission and more likely to be chronically impaired after a diagnosis of a mental health disorder.[19]
Healthy People 2020 findings of persistent disparities in health outcomes and behavioral risk factors by socioeconomic status and education suggest that solutions to improve health outcomes for racial/ethnic and other disadvantaged populations point to upstream social determinants of health, including health care access, utilization, and quality.[20,21] These social and economic conditions, which are the “causes of the causes” of health disparities, vary not only by population characteristics but also by geography.[20] As such, inequities in certain social determinants of health are also assessed in Healthy People 2020 to understand what gives rise to disparities and to identify effective interventions so that all people are given the opportunity to realize the benefits of optimal health. Because of the U.S. political economy (the driver), which structures opportunities (advantages) and disadvantages for individuals, social determinants have been often described by race/ethnicity and income, which are measures of racism and classism, major drivers of social conditions.[3,7,22
Racism is defined as “institutional and individual practices that create and reinforce oppressive systems of race relations whereby people and institutions engaging in discrimination adversely restrict, by judgement and action, the lives of those against whom they discriminate.”[23] Racism is a major social determinant of health disparities. According to Jones, racism occurs on three levels: institutional, personally mediated, and internalized. Institutional racism is defined as “differential access to goods, services and opportunities of society by race.”[24] Personally mediated racism is defined as “prejudice and discrimination where prejudice means differential assumptions about the abilities, motives and intentions of others by race and discrimination is the differential actions toward others according to their race.” An unfortunate consequence of these two forms of racism is internalized racism, which is the “acceptance by members of stigmatized races of negative messages about their own abilities and intrinsic worth.”[24] APHA has recently begun a campaign against racism initiated by Jones.
Disparities in poor health outcomes described by racial/ethnic populations (of which racism is a contributor) place a substantial health burden on the nation and its workforce and give rise to an extreme economic burden.[25] This economic burden, which concerns communities of color but also can spark concern throughout the entire nation, has been quantified and calculated.[26] It is estimated that between 2003 and 2006, eliminating health disparities among racial/ethnic minority populations would have reduced direct medical care expenditures by $230 billion and indirect costs to society (due to loss of productivity from illness and premature death) by more than $1 trillion.[26] This evidence illustrates the cost effectiveness of eliminating racial/ethnic health disparities.
Along with the important health, social, and economic burdens to society based on the existence of health inequities, government and private sectors have a number of legal obligations related to racial equity, disability accessibility, and avoidance of gender-based discrimination. In addition, there is a growing body of legislation designed to prohibit discrimination based on sexual orientation or gender identity.[1] Examples of legal obligations and extent of implementation are described below for housing and education.
Housing: To build healthy communities as outlined in the National Prevention Strategy, all people must have access to safe, affordable, and stable housing. Access to housing has a direct and tangible impact on people’s ability to access quality education as well as on other social determinants of health. Specifically, housing segregation has a direct connection with student poverty rates and inadequate school resources, among other indicators of poor academic outcomes.[27] The federal government passed the Civil Rights Act of 1968 to specifically respond to various ways that American life had been divided based on race. Title VIII of the Civil Rights Act, known as the Fair Housing Act, prohibits race-based discrimination in housing with the express goal of “replacing ghettos” and creating truly integrated neighborhoods.
More recently, potential renters have come up against a new iteration of housing discrimination in the form of online ads. Yet, section 3604(c) of the Fair Housing Act specifically targets media postings (e.g., Craigslist) and prohibits racial discrimination using media platforms. Even with these clear legal obligations prohibiting racial discrimination in renting and home buying, housing segregation persists. Moreover, this systematic grouping of resource-rich and resource-poor neighborhoods[28] has a ripple effect on the ability of certain communities to access stable housing and, in turn, on their access to quality services.
Education: Access to education is a crucial social determinant of health.[29] It has been shown that “[p]eople with less education have higher rates of illness, higher rates of disability, and shorter life expectancies.”[30] However, in the United States, even decades after the landmark civil rights decision by the U.S. Supreme Court in Brown v. Board of Education, education is largely segregated on the basis of race and socioeconomic status.[31] Furthermore, there is no federal or constitutional right to education, and communities must rely primarily on state constitutions and special education laws to ensure equitable access to educational opportunities. K–12 education access is tightly interwoven with access to housing, as in most places students are assigned to schools based on their residence and school districts are divided along the same racial and socioeconomic lines as housing. The Supreme Court has unfortunately held that interdistrict integration is an inappropriate remedy where there has been no finding that wealthier (usually suburban) districts directly contributed to the harm suffered in less affluent districts (Milliken v. Bradley, 1974). In addition to the harm caused by racially segregated school districts, students’ access to quality education is hampered by exclusionary discipline policies that unfairly remove students of color, students with disabilities, and LGBTQ (lesbian, gay, bisexual, transgender, and queer) and non-gender-conforming (GNC) students from the classroom.[32] However, students do have some protections through the Individuals with Disabilities in Education Act, a federal law requiring that students with disabilities receive a free appropriate public education and that parents have a private right of action to demand that their child’s school district develop an educational plan that will allow the student to make meaningful educational progress.
To ensure equitable access to public education, cities and states across the country must commit to redistributing school funding in ways that are equitable and that undo the past and present harm caused by racial housing segregation. Furthermore, communities and districts must commit to eliminating “zero-tolerance policies,” which have been shown to disproportionately exclude youths of color, youths with disabilities, and LGBTQ and GNC students. The American Academy of Pediatrics has released a policy statement detailing that students who have been suspended or expelled are more likely to drop out of high school and calling for a reduction in zero-tolerance policies and an increase of prevention efforts, including early intervention for preschool students and positive behavioral support and interventions within schools.[32] In addition, the American Bar Association’s Joint Task Force on Reversing the School-to-Prison Pipeline called for the removal of zero-tolerance policies from schools and for legislation designed to eliminate criminalization of students for behavior that does not harm others.[33]
Summary: Unfulfilled legal obligations and persistent and pervasive health inequities are major public health problems because inequities cause tremendous health, economic, and ethical burdens for U.S. society, and there is a need for enforcement of legal protections from discrimination. Elimination of health disparities is cost effective, and if nothing is done these societal burdens are projected to worsen as the U.S. population becomes more diverse and multicultural. By 2044, the United States is projected to become a majority-minority country.[34] Furthermore, racial/ethnic minority and low-income populations combined now represent nearly one half of the U.S. population.[34,35]
Evidence-Based Strategies to Address the Problem
While there is not a comprehensive, coordinated strategy for the nation to achieve health equity, there are science- and evidence-based national strategies and initiatives that have demonstrated success in reducing or eliminating some health disparities at the local level and in communities because they have effectively addressed the social determinants of health, including racism and classism. Many are discussed in an Institute of Medicine report titled How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary.[36] Although national initiatives are emphasized as key opportunities, it is realized that their success involves multisector partnerships at every level of government and with nongovernmental, nonprofit organizations. These initiatives are discussed in the context of the Patient Protection and Affordable Care Act and include but are not limited to the following: the dual vaccination strategy, the recommendations of the Community Preventive Services Task Force (CPSTF), Healthy People 2020 goals and objectives, the National Prevention Strategy (NPS), the National Partnership for Action to End Health Disparities (NPA), the Environmental Justice Strategy and Implementation Plan, the Public Health Accreditation Board standards for public health agencies, the Culture of Health initiative of the Robert Wood Johnson Foundation, Association of State and Territorial Health Officials (ASTHO) and National Association of County and City Health Officials (NACCHO) programs and initiatives to achieve health equity, and APHA efforts to achieve the healthiest nation in a generation.
The dual vaccination strategy includes multicomponent, evidence-based interventions designed to reach the general population of children in U.S. communities and targeted interventions designed to reach the most vulnerable children (e.g., those from underserved, low-income, and racial/ethnic minority populations) and high-risk communities (those at risk of vaccine-preventable illnesses because of low vaccination coverage).[37,38] Universal interventions include regular assessments of vaccination services for children at the local, state, and national levels and in health care practices.[37,38] At the health care practice level, the focus is on provision of high-quality vaccination services through practice standards, standing orders, and assessment of services.[39] Targeted interventions, based on the needs of the most vulnerable children, have enabled low-income and racial/ethnic minority children and high-risk communities to gain routine access to health care services via the Vaccines for Children Program. In addition, there is increased awareness of the need for and availability of vaccination services through strategic partnerships between public health agencies and community organizations at all levels of governmental public health, particularly faith-based organizations.[37,38] The Vaccines for Children program specifically provides free vaccines to uninsured and underinsured children.[40]
The evidence-based recommendations of the CPSTF represent examples of interventions proven to improve the quality of health care service delivery. Evidence-based recommendations also exist for communities in reducing risk behaviors for chronic diseases and injuries.[39] These recommendations, when applied to communities, have been proven to improve health.[39]
As mentioned, Healthy People 2020 provides achievable and measurable objectives for improving the health of all that are applicable at the national, state, and local levels.[2,3] Regular and routine monitoring of objectives requires assessments of the overall population at these levels as well as assessments of different groups by education, race/ethnicity, income, disability, and geographic location.[3] This strategy of monitoring the health objectives of individuals in communities, counties, states, and the nation reflects the adage “what gets measured, gets done.”[41]
The NPS, a key national initiative that includes targeted interventions as components, is designed to improve the resilience of all populations by addressing the social determinants of health.[42] The NPS goal is to increase the number of Americans who are healthy at every stage of life.[42] This goal is accomplished via four strategic directions: eliminating health disparities, building healthy and safe communities (e.g., through provision of clean air and water and affordable housing), integrating community and clinical preventive services and enhancing the quality of both, and empowering people to make healthy choices. Elimination of health disparities is applied across the other three directions and nine priority areas to reduce the burden of the leading causes of preventable deaths and major illnesses in the United States.[42] An example of integration of community and clinical preventive services is enabling access to clinical services by providing transportation, child care, and patient navigation interventions.[42] The nine priorities, which include tobacco-free living, prevention of drug abuse and excessive alcohol use, healthy eating, active living, and mental and emotional well-being, can reduce poor health outcomes.[42] Full implementation of the NPS in all communities, including those with substantial racial/ethnic minority and low-income populations, should improve community health.
While education and housing are important social determinants of health, racism (as mentioned) plays a dynamic role in shaping the health and well-being of individuals and populations alike. Throughout the nation, there are a number of efforts taking place at the state and local levels, particularly around building capacity to address racism. Training, webinars, and coalitions and committees formed by national and local organizations provide health departments, hospitals, businesses, and communities with tools and resources to recognize, address, and eliminate racism. Anti-racism training sessions, such as those taught by the Racial Equity Institute, the Center for Racial Justice Innovation, Clear Impact, and the Race Matters Institute, focus on creating racial equity and challenging the status quo.[43–46] These training sessions equip communities and the workforce with knowledge, skills, and resources regarding racial equity. Webinars such as those sponsored by APHA,[47] the Latino Medical Student Association,[48] and Human Impact Partners[49] offer an opportunity to examine the structural barriers that preserve racism while advancing racial and health equity. Coalitions and committees such as Organizing Against Racism, the Interfaith Coalition Against Racism, the United Nations Human Rights Committee on the Elimination of Racial Discrimination, and the International Justice Resource Center’s Committee on the Elimination of Racial Discrimination focus on disassembling racism while promoting justice.[50–53] In addition, organizations such as the National Collaborative for Health Equity, CommonHealth ACTION, the Aspen Institute, the W.K. Kellogg Foundation, and the Center for Ethical Leadership provide funding and resources to organizations in an effort to address the impact of racism.[54–56]
Interventions and initiatives targeting upstream social determinants of health are likely most effective in improving health equity. The NPA, a targeted umbrella initiative led by the Office of Minority Health of the U.S. Department of Health and Human Services (DHHS), is expected to mobilize a nationwide, comprehensive, community-driven, and sustained approach for combating health disparities and for moving the nation toward achieving health equity.[8] Systems-oriented, cross-sector, partnership-based, and community-driven approaches to eliminating health disparities include a national stakeholder strategy for achieving health equity. The goals of this strategy are to increase awareness of the impact of health disparities and actions needed for improving health among racial, ethnic, and underserved populations; to strengthen leadership in addressing health disparities; to improve health and health care outcomes for racial, ethnic, and underserved populations; to improve cultural and linguistic competency and the diversity of the health workforce; and to improve data, research, and diffusion of research and evaluation outcomes.[57] To accomplish the stakeholder plan, there are regional health councils in place. All public health agencies and the private sector could benefit from the guidance of the NPA regional health equity councils and state minority health directors, and they should engage in efforts with community health workers to educate and empower communities and individuals.[58,59] These councils and directors have established trusted partnerships in underserved and minority communities, and they can assist public health agencies in developing community improvement plans.
An example of such endeavors can be seen in the work accomplished by the National Indian Health Board and the National Partnership for Action. To build capacity and improve outcomes for tribal communities, these two organizations have collaborated in a joint effort sponsored by the Office of Minority Health.[60] This effort has provided resources to tribal public health departments surrounding public health accreditation and bolstered “use of the social determinants of health and health equity frameworks in programming and in community health needs assessments.
The 2012 DHHS Environmental Justice Strategy and Implementation Plan delineates actions to address environmental health disparities experienced by minority and low-income populations and American Indian tribes.[36] Environmental justice is defined as fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income in the development, implementation, and enforcement of environmental laws, regulations, and policies.[61] This definition was developed in response to a body of science and community advocacy indicating a disproportionate burden of environmental pollution among minority, low-income, and tribal populations in the United States.[61] The Environmental Justice Strategy and Implementation Plan builds on an earlier strategy from 1995 to protect the health and advance the economic potential of communities overburdened by pollution and other environmental hazards.[61] The four interrelated parts of the 2012 strategy are linked to climate change polices and directives such as policy development and dissemination; education and training; research and data collection, analysis, and utilization; and services.[61] The plan provides a roadmap for DHHS agencies to develop their own environmental justice strategies and plans, to enhance accountability, and to promote collaboration and meaningful community partnerships.
To strengthen the public health infrastructure and improve routine public health agency performance, the Public Health Accreditation Board offers an accreditation process for state, local, tribal, and territorial public health agencies.[62] As of August 2016, 150 local, tribal, and state agencies and one integrated state system of 67 local agencies were accredited.[62] An accredited public health agency meets national standards based on the 10 essential public health services. The accreditation standards drive public health agencies to develop and use documents such as community-driven health improvement plans, agency strategic plans, and emergency operations plans. With accreditation standards, there is strong attention to understanding emerging trends, using assessment data and identifying jurisdiction-specific needs and issues, and addressing health equity, cultural competency, and vulnerable populations. As such, the accreditation process and national standards are driving attention to important topics and actions, which could strengthen the pr
