In the past, health equity focused on access to physicians, geographical proximity to services, and economic status (Bielińska et al., 2022). The concept of health equity has broadened over time to include social and economic factors (social determinants of health). This has led healthcare organizations and providers to recognize the need to address persistently poor health outcomes that affect certain groups (Towe et al., 2021).
Article 12 of the International Covenant on Economic, Social and Cultural Rights of 1966 established that “the right to healthcare is tightly connected to the right to health and that everyone has the right to the enjoyment of the highest attainable standard of physical and mental health” (Bielińska et al., 2022).
Despite this growing interest in health equity, many racial and ethnic minority groups continue to experience disproportionate rates of infectious and chronic diseases and their associated risk factors (Jibrel, 2021). These entrenched negative influences on health in some communities have compounded over generations (Towe et al., 2021).
Eliminating health disparities will save billions of dollars by reducing healthcare costs, improving productivity, and saving lives. Achieving health equity will eliminate gaps in healthcare access, quality of care, and, most importantly, the social and environmental determinants of health (MDHHS, 2019).
Did You Know. . .
A 2018 Kellogg Foundation report “The Business Case for Racial Equity: Michigan” estimated that disparities in health in Michigan represent $2.2 billion in excess medical care costs, $1.9 billion in untapped productivity, and 140,000 lost life years associated with premature deaths each year (MDHHS, 2019).
Social Determinants of Health
Social determinants of health are conditions in the environment that affect a person’s health, functioning, and quality-of-life (ODPHP, 2022). Factors such as economic stability, transportation, quality education, healthy food, access to quality healthcare, and the built environment contribute to variability in lifespan and quality of life (Towe et al., 2021).
Social determinants of health are often grouped into the 5 domains illustrated above. Source: ODPHP. See References for citation and web address.
Disparities related to social determinants of health are hard to ignore:
- Black Americans are 5.1 times more likely than White Americans to be incarcerated.
- Black Americans earn 61 cents for every dollar White Americans earn (and Hispanic Americans earn 74 cents).
- Lower income people are more likely than higher income people to lack access to care and have poorer self-reported general health (Towe et al., 2021).
Most Americans are unaware of these social determinants, do not understand what causes them, and do not necessarily find them to be unfair. In 2008–2009, a national survey showed that 73% of respondents were aware of health differences between the poor and middle-class people, but less than half reported awareness of health differences between White and Black Americans. Many respondents placed the responsibility for poor outcomes on individual behaviors such as smoking, diet, and exercise, as well as access to clinical care, and less on the social determinants of health (Towe et al., 2021).
Gender is an important and often overlooked social determinant of health and the damage caused by gender inequality across the globe is immense (Alcalde-Rubio et al., 2020). It is one of the core social determinants of population health and health inequalities (Miani et al., 2021).
Gender becomes an important social determinant of health through a variety of social factors: health system discrimination and bias, inequitable societal norms and practices, differential exposure to disease, disability, and injuries, and biases in health research. On a global scale, the burden of gender inequality drives large-scale excess in mortality and morbidity (UCL, 2020).
Barriers to accessing healthcare services are consistent across countries and disproportionally affect people with below-average income, immigrants, people with chronic conditions, and people with mental health conditions. Immigrants are more likely to experience multiple barriers, particularly after reaching care (Corscadden et al., 2018).
Structural racism, lack of health insurance, rural healthcare disparities, gender discrimination and violence, minority health disparities, and redlining and gentrification are some of the barriers faced in accessing health services. Adding to the picture, research, testing, and screening tools often fail to address the needs of ethnic and minority patients.
What is Structural Racism?
Structural racism means public policies, institutional practices, cultural representations, and other norms perpetuate racial group inequity. It is rooted in a hierarchy that privileges one race over another, influencing institutions that govern daily life, from housing policies to police profiling and incarceration. It is associated with social determinants of health and health disparities (Muramatsu and Chin, 2022).
Structural racism produces and reproduces differential access to power and to life opportunities due to race and ethnicity. Over centuries, structural racism has become entrenched, influencing the way medicine is taught and practiced as well as the functioning of healthcare organizations (Geneviève et al., 2020).
One example of structural racism in medicine has to do with pregnancy outcomes. A study published by Amnesty International found that some healthcare providers fail to consider the healthcare needs of women of color, treat them poorly, and sometimes even try to dissuade them from seeking medical care. Systemic factors such as these regulate access to healthcare services and ultimately influence the quality of care (Geneviève et al., 2020).
Video: Dorothy Roberts: The problem with race-based medicine [14:27]
Source: TEDMED, 2015.
The effects of race-based medicine were evident during the COVID pandemic. A tool commonly used to assess a person’s oxygen saturation appears to be more accurate for light-skinned patients than darker-skinned patients.
Pulse oximetry was used extensively during the COVID pandemic and critical treatment decisions were made partly based upon a person’s oxygen saturation. For some patients, life-saving therapies were delayed because pulse oximeters over-estimated oxygen saturation levels in darker-skinned individuals. There is evidence that, for Black and Hispanic patients, undetected low oxygen levels led to delays in receiving therapies such as remdesivir and dexamethasone, and in many cases, led to no treatment at all (Fawzy et al., 2022).
Although pulse oximetry is a fundamental tool used in diagnosis and management decisions, the device’s lack of accuracy in certain populations has not been adequately investigated. This is even though the issue has been recognized for several decades and was highlighted in a 2020 safety communication by the Food and Drug Administration (Fawzy et al., 2022).
Adding to the problems, pulse oximeters have migrated out of the acute care setting and are now available and affordable to the average consumer for home use. The expanded use of a differentially inaccurate device potentially exacerbates racial and ethnic health disparities (Fawzy et al., 2022).
Lack of health insurance—or being under-insured—is a critical barrier to accessing healthcare services. Health insurance is a key factor in whether, when, and where people get medical care. Uninsured people are far more likely than those with insurance to postpone or forego healthcare. And being uninsured can have severe financial consequences, with many unable to pay their medical bills, resulting in medical debt (Guth and Artiga, 2022).
Despite most people of color having a full-time worker in the family, they are often employed in low-wage jobs that are less likely to offer health insurance. While private insurance is the largest source of health coverage for people across racial and ethnic groups, people of color are less likely to be privately insured than White people (Guth and Artiga, 2022).
Rural populations make up around ~19% of the U.S. population. These areas have heightened mortality rates from several chronic diseases compared to urban populations (Nuako et al., 2022). A lack of rural hospitals and clinics, lack of access to specialty services, and high turnover rates among healthcare providers, are significant barriers for rural communities.
Rural-urban mortality disparities have grown over recent decades despite overall declines in mortality from chronic disease conditions. The causes of rural health disparities include higher rates of poverty, behavioral risk factors, larger proportions of older adults and people with disabilities, and lower rates of insurance and education (Nuako et al., 2022).
Gender Discrimination in Healthcare
Throughout history, women have been victims of bias and discrimination in medical diagnosis, treatment, and care. Women are less likely to be diagnosed with a non-psychosomatic illness, have their pain treated, and have their symptoms be taken seriously compared to men. Women were also excluded from clinical trials until the early 1990s (Luu, 2021).
Historically, women’s physical complaints were believed to be connected to the female reproductive system. During the 18th and 19th centuries, female hysteria was a common diagnosis and illnesses experienced by women were often attributed to psychological problems (Luu, 2021).
Gender discrimination in healthcare is highlighted by findings described in several studies. For example—in Austria women undergoing hemodialysis were less likely to be treated via a vascular shunt and less likely to be referred for kidney transplantation (Shai, et al., 2021). Indigenous and non-White Hispanic patients have been stereotyped as being non-compliant with clinical health recommendations, having risky health behavior, and difficulty understanding or communicating health information (Dirks et al, 2022).
Women are less likely than men to be referred for cardiovascular testing and Indigenous women in particular report perceived discrimination by clinicians as a reason for not seeking recommended cancer screening (Dirks et al, 2022).
The recognition of gender bias in the clinical management of cardiovascular disease, has led to research into other health issues affecting women. In 2019, Nature Communications published a study analyzing health data for almost 7 million men and women in the Danish healthcare system over a 21-year period. The results showed that women were diagnosed later than men in more than 700 diseases (Alcalde-Rubio et al., 2020).
Did You Know. . .
From the 1910s through the 1950s, and in some places into the 1960s and 1970s, tens of thousands—perhaps hundreds of thousands—of American women were detained and forcibly examined for sexually transmitted infections. The program was modeled after similar ones in Europe, under which authorities stalked “suspicious” women, arresting, testing, and imprisoning them.
If the women tested positive, U.S. officials locked them away in penal institutions with no due process. While many records of the program have since been lost or destroyed, women’s forced internment ranged from a few days to many months. Inside these institutions, the women were often injected with mercury and forced to ingest arsenic-based drugs, the most common treatments for syphilis in the early part of the century. If they misbehaved, or if they failed to show “proper” ladylike deference, these women could be beaten, doused with cold water, thrown into solitary confinement—or even sterilized.
Scott W. Stern
America's Forgotten Mass Imprisonment of Women Believed to Be Sexually Immoral, 2019
The Health Impacts of Violence Against Women
Exposure to physical and sexual violence in childhood and adulthood can have a profound and prolonged impact on a woman’s health. Studies have shown an association between childhood abuse and cardiovascular, autoimmune, and metabolic diseases, chronic pain, and mortality in women. Biological changes have been noted in abuse survivors such as increased pituitary stress response, increased inflammation, and even DNA changes (Shai, et al., 2021).
Pregnancy-Related Health Disparities and Barriers
Structural racism can affect pregnancy outcomes. An Amnesty International publication reported that some healthcare providers fail to consider the healthcare needs of women of color, treat them poorly, and sometimes even try to dissuade them from seeking medical care. Systemic factors such as these regulate access to healthcare services and ultimately influence the quality of care (Geneviève et al., 2020).
More than 700 women die annually in the U.S. during pregnancy or its complications. During 2007–2016, Black and American Indian/Alaska Native women had significantly more pregnancy-related deaths per 100,000 births than did White, Hispanic, and Asian/Pacific Islander women. Disparities have persisted over time and across age groups and were present even in states with the lowest pregnancy-related mortality rates and among groups with higher levels of education (Petersen et al., 2019).
A review of maternal mortality in 13 states indicated that 60% of pregnancy-related deaths were preventable. Chronic diseases such as hypertension, which is associated with increased risk for pregnancy-related mortality, is more prevalent and less well-controlled in Black women (Petersen et al., 2019).
Gaps in healthcare coverage and preventive care, lack of coordinated healthcare and social services, and community factors such as transportation and housing contribute to pregnancy-related deaths. Addressing these factors and ensuring that pregnant women at high risk for complications receive specialized care in facilities can improve outcomes (Petersen et al., 2019).
Did You Know. . .
In 1970, the Family Planning Services and Population Research Act of 1970, led to nearly one in four Native American women of childbearing age being sterilized without their consent. This policy remained in effect until 1976. At the same time, the Hyde Amendment (first passed in 1976 and amended in 1993) made it illegal to use federal funds for abortion services and denied Native American women access to reproductive health services through lack of funding to Indian Health Services (Yellow Horse et al., 2020).
In states that have not implemented the Affordable Care Act Medicaid expansion, people can lose coverage at the end of the postpartum period. The American Rescue Plan Act includes a new option for states to extend pregnancy-related Medicaid coverage from 60 days postpartum to 12 months (beginning in April 2022), which could decrease the number of people becoming uninsured at the end of the 60-day postpartum period. At least 26 states plan to take up the American Rescue Plan Act option or otherwise extend postpartum coverage (Guth and Artiga, 2022).
Quality of Maternity Care
A national study of five specific pregnancy complications found a similar prevalence of complications among Black and White women, but a significantly higher case-fatality rate among Black women. Studies have suggested that Black women are more likely than are White women to receive obstetric care in hospitals that provide a lower quality of care (Petersen et al., 2019).
The recent Supreme Court ruling overturning Roe v. Wade has already impacted pregnancy-related healthcare for many women. It has also impacted OB/GYN training in the 26 states that have restricted or are poised to restrict abortion services. This means hospitals will no longer offer vital training used to manage miscarriages and other pregnancy-related complications.
Did You Know. . .
Black and American Indian/Alaska Native people are more likely to die while pregnant or within a year of the end of pregnancy compared to White people. One study estimated that a total abortion ban in the U.S. would increase the number of pregnancy-related deaths by 21% for all women and 33% among Black women (KFF, 2022).
Minority Health Disparities
Disparities in healthcare and health outcomes exist in both publicly and privately funded health programs. Racial and ethnic minority populations experience worse outcomes than the general population for almost every health condition.
Michigan Department of Health and Human Services, 2019
The National Institute on Minority Health and Health Disparities has designated certain groups as most affected by health disparities in the United States: Blacks/African Americans, Hispanics/Latinos, American Indians/Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islanders, as well as socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minorities (Mapes et al., 2020).
Many people in these groups experience disparities and barriers related to financial concerns and unemployment. Lack of health literacy and communication and language barriers add to the picture. Cultural factors, discrimination, and structural factors such as lack of transportation create sometimes unsurmountable barriers to care (Mapes et al., 2020).
Disparities Cause by Redlining and Gentrification
Redlining and gentrification are social practices that we may not consider as contributing to gaps in health. Redlining is a practice in which lenders deny mortgages to eligible buyers solely because of their race. This practice, once widespread, assured that people of color were denied the right of home ownership and upward economic mobility that millions of White people enjoyed. Redlining has been succeeded by gentrification, whereby middle-class White people move into urban areas and displace Black people who have lived in a neighborhood for years (Julian, Hardeman, and Huerto, 2020).
Both redlining and gentrification perpetuate poverty in communities of color. As such, many Black and low-income Americans live in communities where clean water isn’t guaranteed, and social distancing is nearly impossible in crowded homes. In this way, redlining and gentrification impact the racial inequities seen during the COVID-19 pandemic (Julian, Hardeman, and Huerto, 2020).
Resources that enhance quality of life, such as safe and affordable housing, access to education, public safety, availability of healthy foods, local health services, and environments free of life-threatening toxins can have a significant influence on population health outcomes (ODPHP, 2022).
The LGBTQ+ Community
Clinicians may harbor implicit prejudices that negatively impact healthcare quality and access for lesbian, gay, bisexual, transgender, and queer/questioning individuals. Although implicit healthcare biases may be largely unintentional, they operate at interpersonal, institutional, and societal levels (Dirks et al, 2022).
LGBTQ+ individuals face significant disparities in physical and mental health outcomes. Compared to their heterosexual counterparts, LGBTQ+ patients have higher rates of anal cancer, asthma, cardiovascular disease, obesity, substance abuse, cigarette smoking, and suicide (Morris et al., 2019).
Sexual minority women report fewer lifetime Pap tests, transgender youth have less access to health care, and LGBTQ+ individuals are more likely to delay or avoid necessary medical care compared to heterosexual individuals. These disparities are due, in part, to lower healthcare utilization by LGBTQ+ individuals (Morris et al., 2019).
Perceived discrimination from healthcare providers and denial of healthcare altogether are common experiences among LGBTQ+ patients and have been identified as contributing factors to health disparities. Disparities in healthcare access and outcomes experienced by LGBTQ+ patients are compounded by vulnerabilities linked to racial identity and geographic location (Morris et al., 2019).