Race and Health Equity in America

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0:00:05 Nancy Fleischer: Related to health equity, we see that almost regardless of what health outcome you're looking at people from disadvantaged groups have worse health outcomes. So that tells us that it's not about genes or a particular health outcome. That it's about structural systems that are in place that are creating these inequities.

0:00:25 Narrator: Hello and welcome to Population Healthy, a podcast produced by the University of Michigan School of Public Health. In this season of Population Healthy, we'll examine health inequities through the lens of race in America by talking to public health researchers, experts and others to learn more about what can be done to work toward health equity in our communities and across our country. This is Population Healthy season three: Race, Inequity, and Closing the Health Gap.

We begin our journey to a better understanding of race and health inequity with Minal Patel, an associate professor of Health Behavior and Health Education at the University of Michigan School of Public Health. Dr. Patel introduces us to Mr. Jones.

0:01:12 Minal Patel: So let me tell you about Mr. Jones. So Mr. Jones is among the one in 10 Americans who has diabetes, and among one-third of people with diabetes who still do not meet general targets for glycemic blood pressure or cholesterol control. It's not really for a lack of health insurance because Mr. Jones is indeed insured and on a treatment regimen, and the Affordable Care Act significantly increased access to care for many individuals with diabetes, and we see coverage rates at 90% for people between the ages of 18 and 64 in 2016, and near universal coverage for those greater than 65 years of age.

0:01:54 Patel: So there must be other factors beyond insurance coverage in the standard provision of medical treatment that drive Mr. Jones' poorly controlled disease, so there are indeed other factors when we think about the social determinants of health. Social determinants are major drivers of health inequities observed in diabetes morbidity and mortality. So Mr. Jones, he has a primary care doctor, but where he seeks care lacks a multidisciplinary care team approach and health system investment in a comprehensive infrastructure to manage chronic disease.

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0:02:33 Narrator: So how do we begin to unpack those complex systems that are challenging Mr. Jones' ability to manage his health, and what do we call them? For an explanation, we bring in Enrique Neblett, a professor of Health Behavior and Health Education at the University of Michigan School of Public Health, and one of the nation's leading scholars on racism and health.

0:02:52 Enrique Neblett: Structural racism refers to a system of interpersonal, institutional, cultural, and historical actions, practices, policies, and norms that interact to shape and perpetuate inequality between and among racial and ethnic groups. Structural racism is often characterized by the preferential treatment and privilege and power of white folks as opposed to those same opportunities for people of color, so black, Latino, Asian, American Indian and racially oppressed people. I think that it's really important that we focus our interventions on the institutional and cultural levels, because we know that even if interpersonal discrimination were completely eliminated because racism is part of a structure of society, racial inequities would likely remain unchanged due to the persistence of those same structural factors.

Some classic examples of health disparities include things like life expectancy, mortality, or death rates, and even the incidence and prevalence of different diseases. So if we think about one of the most common examples that people say has to do with how long people live. We know, for example, that black Americans, on average, tend to live four to five years shorter than non-Hispanic whites. Things differ a little bit when you look at gender differences, but on average, they don't live as long. When we would think about things like mortality data, we know that blacks and African-Americans, also American Indians are more likely to die of things like diabetes and heart disease and cancer relative to non-Hispanic whites.

0:04:52 Neblett: On the other hand, groups like Asian-Pacific Islanders have lower death rates of some of these same disorders and diseases. We also see these types of disparities in terms of infant mortality and pregnancy-related deaths. So we know when we look at infant mortality that non-Hispanic blacks had infant mortality rates that are two to three times the rates for non-Hispanic whites, and you see a similar pattern with pregnancy-related deaths, whereby black and American Indian, Alaska native women are two to three times more likely to die from pregnancy-related causes. Some groups are more impacted by these kinds of health disparities because of the disproportionate impact of the social determinants of health.

 We know that African Americans, black Americans are more likely to be exposed to poverty. They're more likely to experience poor education, because of some of these kind of structural factors that include things like systemic racism and other historical forces and practices like redlining, segregation practices, incarceration, so on and so forth. And so if you're disproportionally more likely to be impacted by things like food insecurity, financial insecurity as a result of systemic disinvestment in communities and some of these other system factors, your health outcomes are more likely to be adversely impacted.

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0:06:36 Narrator: These structures of inequity touch every aspect of our lives and can become difficult to study on their own, says Nancy Fleischer, Associate Professor of Epidemiology at the University of Michigan School of Public Health.

0:06:51 Fleischer: Structural racism affects many parts of the health system, including access to health insurance, access to preventive care, and seek care and interactions with members of the health care system, but the effects of structural racism on the health system are very difficult to disentangle from the broader societal systems. So for example, in the United States, health insurance is closely tied to employment because structural racism affects all sectors in society that includes limiting opportunities to education, which can limit opportunities to good jobs with benefits including health insurance. And access to healthcare is another example, because neighborhoods have been segregated for generations by race due to policies like redlining, access to opportunities and resources including hospitals and clinics are often limited to minority populations in this country. And because of the restriction of educational and economic opportunities in the United States, due to these underlying structural factors, race really cannot be separated from other social determinants of health.

0:07:52 Narrator: Dr. Neblett introduced us to the term social determinants of health, the wide range of factors that can affect our health, each of which deserves scientific scrutiny. You'll hear Dr. Patel first and then Dr. Neblett.

0:08:04 Patel: The social determinants of health are conditions in the environment in which people are born, live, learn, work, play, worship and age that affects a wide range of health, functioning, and quality of life outcomes and health risks. These social determinants include things like access to social and economic opportunities, the resources and supports available in our homes, neighborhoods, and communities. The quality of our schooling, the safety of our workplaces, the cleanliness of our water, food, and air, and the nature of our social interactions and relationships. The social determinants actually explain more about our health outcomes in Biology and the provision of medical treatment.

0:08:48 Neblett: Social determinants of health are often shaped by things like money, power, and the resources that folks have available to them, and they include things like discrimination and social exclusion, early life experiences, so things like trauma early on in life, poor education, unemployment and job insecurity, poverty and income inequality, food insecurity and poor housing quality, and then there are also things like adverse features of the built environment. So I was thinking about like the presence of green space in communities, access to transportation systems and poor access to healthcare. These are some examples of social determinants of health.

Oftentimes, we think of social determinants of health as the fundamental causes of health, sometimes you'll hear people refer to the causes of the causes, and I think one of the reasons that it's vital to understand social determinants of health is because if we want to improve the health of all people and we don't understand the root factors or root causes that shape health, then it would be difficult to actually address and improve the policies and programs that can really help.

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0:10:13 Narrator: When researchers make broad claims about the factors that affect our health, it's natural to ask how we know health inequities exist and how we study them. Belinda Needham is an Associate Professor of Epidemiology at the University of Michigan School of Public Health. She'll explain where the data comes from.

0:10:29 Belinda Needham: A lot of what we know about disparities comes from studies that are run by the National Center for Health Statistics at the Centers for Disease Control and Prevention. And so these studies are sort of federally mandated studies that are designed to monitor the health of the population. So there's the National Health and Nutrition Examination Survey, the National Health Interview Survey, and then the Behavioral Risk Factor Surveillance System. For specific diseases like cancer, we have national registries that collect data that can be used to monitor disparities. And then also all federally funded research studies are required to collect data on gender and race and ethnicity, and so that allows us to quantify disparities along those dimensions in research studies that are funded by the federal government.

0:11:16 Narrator Let's go back to Dr. Fleischer.

0:11:19 Fleischer: Public health experts study disparities and infectious and chronic diseases for many reasons. In order to improve population health, we need to understand who is most affected by different diseases, so we can effectively target interventions to reduce that disease burden, but these interventions are often outside of the healthcare system. So health systems and healthcare professionals often only see people after they become sick, but in Public Health, our goal is to prevent people from getting sick in the first place.

So for example, in the United States, the place that you live can determine how good the school is that your children will go to, whether or not you will be able to easily access healthcare and the opportunities that you have for employment that offers regular hours and benefits like health insurance. One of the core functions of public health is surveillance, and so by regularly gathering data on the US population, we can quantify how many people have different kinds of the infectious and chronic diseases.

0:12:11 Fleischer: So public health surveillance happens in different ways, and we're seeing that in action right now with the COVID-19 response. We often gather data on things like chronic diseases and health behaviors and mental health outcomes, and also some infectious diseases by conducting surveys of people all across the United States. And in these surveys, we ask about different health outcomes as well as information about socioeconomic and demographic factors, and we can use this information to quantify the proportion of people who belong to different racial and ethnic groups, for example, who have specific health outcomes.

We can also look at differences for other socially disadvantaged groups, including people who have low educational attainment or low income, and other ways that we learn information about many infectious diseases and some other conditions like lead poisoning through the Nationally Notifiable Diseases surveillance system. COVID-19 is now a notifiable disease. Clinicians are required to report cases to the public health system.

0:13:05 Narrator: Using that data, researchers then develop studies to help us understand specific outcomes of health inequity, so that we create interventions to help prevent disease and other negative health outcomes. Dr. Fleischer's research helps shed some light on that.

0:13:19 Fleischer: Two areas of my research include tobacco use and also adverse birth outcomes. So if we look at tobacco, for example, we see that people who have lower educational attainment and lower incomes smoke at higher rates. Of course, smoking is a key risk factor for many chronic diseases, and so we often see that reflected in the patterns of disease for other outcomes like cardiovascular disease, diabetes, and other outcomes. I also do work looking at racial and ethnic disparities in birth outcomes, so mothers giving birth to preterm babies or babies with low birth weights, and there the racial disparities are very stark, where black women have higher rates of having preterm and low birth weight babies compared to white women.

0:14:07 Narrator: Once again, here's Dr. Needham.

0:14:09 Needham: Right now we're observing large disparities in COVID-19. The patterns that we're seeing in that disease are actually very similar to patterns that we see in many other diseases. There's differences in access to care, and that is looped to larger factors like residential segregation and where hospitals and care locations are located, and also to things like transportation systems that determine how people are able to get to hospitals and other healthcare facilities. We also know that there's disparities in quality of care, and that's independent of whether people have insurance or not, and that could be linked to things like provider bias, implicit bias that physicians have, which kind of determine the way they differentially treat patients by race.

When we think about outside of the healthcare system, there are many systems that impact health and that impact racial disparities and health. This is sort of why we use this term systemic racism, and that's because it's really affecting all of these different institutions and societal systems that impact people. These include things like the education system, employment, housing, banking, criminal justice, even the media, any institution that you can think of, we have racism present in those systems, and most of these things are very important for help. So if we think about education and employment, for example, you know that people who have higher levels of education have better health for a number of reasons.

One reason is because they're more likely to be employed and to have income, which increases the sort of material resources that they have to protect their health and to manage health conditions once they have them. It also impacts a lot of psychosocial factors, like the sense of personal control. So we know that people who have higher levels of education have a greater sense that they have control over the things that happen in their lives, but if you think about this example of a vaccine, if I have the sense that I can go and I can get this vaccine and I understand how it will reduce my risk of getting a disease, and I feel confident that I can go and do that, then it's more likely to happen.

0:16:23 Narrator: With so many aspects of culture and society that impacts our health, how can we help Mr. Jones?

0:16:30 Patel: Mr. Jones has experienced unemployment multiple times over the past three years because of increased absenteeism as a result of his poorly-controlled diabetes. His cyclical income has also made him food insecure, and he typically rations his food at the end of the month, in order to pay his electricity bill. Last year, Mr. Jones moved to an area of town that was more affordable to him, what would typically be described as a low-income area. Mr. Jones' new community is also considered a food desert because it is more than a mile away from a large grocery store. Mr. Jones is in a neighborhood that also shows signs of physical disorder such as dilapidated housing, few recreational spaces and broken glass on the ground.

Mr. Jones does not want to go outside for exercise, and these features also create barriers to economic investment in his overall community. The social determinants play a significant role in shaping health outcomes, and in the case of Mr. Jones, his diabetes outcomes.

0:17:31 Narrator: The coronavirus pandemic, illuminated once again with tragic clarity, what we knew about the differences in disease burden from one community to another. Dr. Neblett explains.

0:17:42 Neblett: The pandemic has affected certain groups more than others, and black Americans, in particular, for a number of reasons. Black Americans, for example, are more likely to have lung disease, asthma, and other types of conditions that increase vulnerability to illness and deaths from COVID-19. Black Americans and certainly other racial and ethnic minority groups are more likely to work in jobs that increase the vulnerability to COVID-19 exposure. Early on, there was a lot of conversation around essential jobs and essential workers, folks who are working those jobs are putting themselves on the line and in terms of close-contact with others and not having the option to work from home. Along the same lines in terms of the importance of the job, some of these same jobs are less likely to offer critical benefits such as health insurance that we know are... They're really important.

Some other factors that folks have discussed center around disparities in access to testing bias and the requirements for who could get tested, how long it can take to get the results, access to affordable housing has implications for crowding in close quarters and multigenerational housing. So all of these things are factors that explain why some groups are affected more than others. I think one last thing that I would add would be that there's been differential levels of stress, so it's not just oh, this is Coronavirus, and that's stressful, but black-Americans are more likely to know someone who has died or been impacted by Coronavirus.

And so there's been a lot of writing in recent weeks and months about the relentlessness of black grief, for example, and how folks are having to say goodbye to their loved ones if they're even able to do that, sometimes they're not. I mean we can't have funerals and say goodbye in some of the ways that we're accustomed to doing.

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0:19:45 Neblett: Just because we have a treatment or we have a prevention like a vaccine, it doesn't mean that everyone will have access to it even if it's free, because there's these other things that determine even whether you know about the availability of this vaccine or this treatment, whether you trust people in the healthcare system enough to go and get the vaccine or to get the treatment, there's also really practical things like having transportation or being able to take time off of work to be able to go to the doctor. There's all sorts of resources that people need to have, in order to take advantage of therapies or treatment.

Sometimes we think about universal healthcare being something that would eliminate health disparities, but we know from other countries that have universal access to healthcare, that disparities persist. They may be somewhat smaller, but they persist because healthcare isn't really what makes us sick or what makes us healthy for many condition, and also because access to healthcare just sort of isn't sufficient to address all of the differences in resources between more and less advantaged groups that allow them to take advantage of therapies or treatments, if they do exist.

0:20:59 Narrator: In this season of the Population Healthy podcasts, we will have in-depth discussions on race and racism and how these affect everyone's health, especially the health of black, indigenous, and people of color.

0:21:10 Fleischer: Every system is affected by this, the healthcare system, educational system, the criminal justice system, the housing system, and the economic system, they all need to be reformed. Residential segregation is a key factor that leads to other forms of segregation, including educational segregation and the limiting of opportunities there, and so although residential segregation is not an easy fix, it would lead to other downstream fixes in terms of educational opportunity and economic opportunity. Changing the way our school systems are funded, so not funded based on the wealth in the neighborhood that you live in. There are many examples and certainly now we're talking a lot about reforming the criminal justice system, which is also something that has to be done. And I think that everybody can look in their communities and their workplaces and their school systems and think about what structural changes could be made to make them anti-racist.

0:22:08 Needham: We can't eliminate racial health disparities without eliminating racism because it's the fundamental cause. It is the thing that is driving health disparities, and so if we don't address it, we're likely to fail if our goal is to eliminate health disparities. One of the things that happens is when people do start thinking about it, their initial reaction, a lot of times, particularly white people or people who benefit from the systems of oppression is to feel guilty. That feeling of guilt can sometimes motivate you to take action, but other times you can kind of get stuck there in that feeling, and it's not really the best motivation for taking effective action. There is an important purpose for guilt, raising your awareness of something being wrong, but I don't think that feeling guilty about racism really does anything to make it better.

As public health professionals, we really have to acknowledge that health disparities are just one consequence of this larger problem of racism that produces inequalities in pretty much every aspect of life, not just health. I think what that means is that ultimately we have to change the culture of white supremacy that's been in place for many hundreds of years and has resulted in the accumulation of advantages for people of European descent, or people that we refer to as white and the accumulation of disadvantages for everyone else, and particularly for people of African descent, who we refer to as African-Americans or black in the US.

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0:23:40 Narrator: On the next edition of Population Healthy.

0:23:43 Speaker: For patients of color who feel like their doctors, their providers are not responding or listening to them or respecting them, can lead to lower levels of trust, and that has consequences. Lower trust can even lead to avoiding healthcare, in general.

0:24:06 Narrator: Thanks for listening to this episode of Population Healthy: Race, Inequity, and Closing the Health Gap from the University of Michigan School of Public Health. We hope you learned something that will help you make the world a healthier place. Please subscribe or follow our podcast on Apple Podcast, Google Play, Stitcher, Spotify or wherever you listen to podcasts. Interested in studying public health with us? Join our interest list by going to our homepage, publichealth.umich.edu, and check out our programs and degrees and other helpful resources across our website.

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