How are the two related?
While it’s always been present, it’s been gaining national attention in the past year or so. What is it? Social injustice. Without a doubt, it affects all aspects of life. One of the most concerning is health. What are the differences? What should be done to correct them?
Social justice is the concept that everyone deserves equal rights and opportunities, including the right to good health. The idea behind this is that we all have innate value as human beings, and no person’s value is higher or lower than anyone else’s. Healthy people 2020 defines health equity as attaining the highest level of health for all people and requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and health and healthcare disparities.
The inequities are avoidable, unnecessary, and unjust. Many of these result from policies and practices that create an unequal distribution of money, power, and resources among communities. Often, they’re based on race, class, gender, place, and other factors. The effects ripple through society, impacting education, representation, healthcare, and law enforcement. These disparities have been documented for decades and reflect longstanding structural and systemic inequities. According to Healthy People 2020, a health disparity is “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage” that “adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”
Research shows that health outcomes are driven by multiple factors, including underlying genetics, health behaviors, social and environmental factors, and access to healthcare. There is currently no consensus on the magnitude of the relative contributions of each of these factors, but they’re thought to be the primary drivers that shape individuals’ health. When it comes to research, characteristics, like the design, input, analysis, and application of data, can be affected by social injustice. This means the data might not equitably represent people across all backgrounds, which places black, Asian, and minority ethnic (BAME) groups at a further disadvantage.
In the early 2000s, two Surgeon General’s reports recognized the impact of health disparities by looking at the difference in tobacco use and access to mental health care by race and ethnicity. Despite the recognition and documentation of these and other inequalities, many gaps have persisted, and, in some cases, widened. A National Institutes of Health (NIH) study in 2000 attributed more than a half-million deaths to heart attacks, strokes, and lung cancer. Of these, 245,000 were attributable to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 39,000 to area-level poverty, and 119,000 to income inequality. While the link between such social factors and poor health is complicated, the authors say “evidence points to mechanisms including risky health behaviors (e.g., smoking), inadequate access to healthcare, poor nutrition, housing conditions, or work environments.” The report further states, “Negative social interactions, including discrimination, have been linked to elevated mortality rates, potentially through adverse effects on mental and physical health as well as decreased access to resources.” Overall, NIH’s conclusions reveal the need for “a policy approach that considers how social factors can be addressed to improve the health of populations.”
Over the past 25 years, the life expectancy of the richest Americans has increased, while the life expectancy of the middle 60% hasn’t changed, and that the life expectancy of the poorest 20% has actually decreased. This information is further evidenced by a study in the Journal of the American Medical Association (JAMA), which found that the life expectancy divide is widest among the richest and poorest in US society. The study discovered that men in the top 1% of the income distribution are expected to live 15 years longer than those in the bottom 1%. For women, the difference is about ten years. According to World Health Organization (WHO) and World Bank data, people live longer in nations with lower levels of inequality. Their statistics show that the average life expectancy in the US is four years shorter than in similar countries.
An analysis from the Kaiser Family Foundation (KFF) agrees with the concept that social and economic inequities have an enormous impact on health disparities. People of color fare worse than white people in most areas of health status, including physical and mental health, birth risks, infant mortality rates, HIV and AIDS diagnosis and death rates, and the prevalence of and death rates due to certain chronic conditions. Specifically, Black and American Indian or Alaska Native (AIAN) people have an infant mortality rate nearly twice that of white people. The US has the largest gap between the rich and the rest of the population when it comes to infant mortality rate (5.7 per 1,000 live births) compared to other comparable countries. When it comes to HIV diagnosis, Black teens and adults have a nearly eight times higher rate than whites and a nearly ten times higher AIDS diagnosis rate. For Hispanics, HIV and AIDS diagnosis rates are more than three times higher than that of whites. People of color and lower-income individuals also receive inferior quality of care. Recent KFF survey data found that Black adults are more likely than white adults to report certain negative healthcare experiences, like a provider not believing them and refusing them a test, treatment, or pain medication they thought they needed.
The health impacts of inequality are numerous. One study in the Journal of the American College of Cardiology from 2019 found that the higher the level of income inequality, the higher the rate of cardiovascular-related deaths and hospitalizations. American Cancer Society data shows that affluent counties have significantly lower levels of cancer deaths than poor counties. The American Psychological Association printed a report that shows that US households with annual incomes below $50,000 have higher stress levels than other families. In addition to higher stress levels, food deserts and lack of recreational facilities in poor communities contribute to higher obesity rates among low-income individuals. According to the CDC, smoking rates vary widely by income, with 12.1% of individuals smoking in households earning more than $100,000 per year versus 32.2% in households earning less than $20,000 per year. Individuals who rank lower on the national economic ladder are more likely to have physically demanding jobs, leading to more stress, both physical and mental. The Brookings Institution calculates that the bottom third of US earners tend to retire earlier than other Americans because their jobs are often more physically demanding. This means they’re unable to claim full retirement benefits, exacerbating the economic inequality.
However, it’s important to note that greater economic inequality appears to lead to worse health outcomes for all individuals in a society, not just the poor. This is because inequality reduces social cohesion, a dynamic that leads to more stress, fear, and insecurity for everyone. As a country, the US spends far more on healthcare than any other country globally but has far worse health outcomes than any of our peer countries. Part of the reason is we devote a significant amount of resources to delivering medical care, but very few resources towards correcting the underlying social, economic, and cultural structures that influence the health inequities. In other peer countries, most have some form of governmental healthcare guaranteed for all citizens, but the US doesn’t. Instead, many Americans rely on their employers for health insurance. This is problematic because when they are out of work or working in part-time positions faced with massive healthcare bills due to an accident or sudden illness, they can’t afford treatment. Per data from CNBC, two-thirds of people who file for bankruptcy in the US do so because of medical issues. As a result, people are calling for the US to adopt some version of expanded, universal, government-run healthcare similar to Medicare and Medicaid. Research shows that this could reduce the disparities in health coverage and outcomes for Black and Hispanic individuals, particularly for maternal and infant health measures. It would also cut down on the high cost of medication and prevent people from falling into financial ruin due to a health issue. Over 30% of direct medical costs faced by Blacks, Hispanics, and Asian-Americans can be tied to health inequities. That’s more than $230 billion over a four-year period. Research finds that health disparities are costly not only to individuals but to society. It’s estimated that disparities amount to approximately $93 billion in excess medical care costs and $42 billion in lost productivity per year. This doesn’t take into account additional economic losses due to premature deaths.
The Affordable Care Act was aimed toward this goal by expanding health insurance coverage. While it did lead to large gains, people of color and low-income individuals remain at increased risk of being uninsured. Unfortunately, starting in 2017, coverage gains stalled and began reversing because of actions taken by the Trump administration. These included decreased funding for outreach and enrollment assistance, approval of state waivers to add new eligibility restrictions for Medicaid coverage, and immigration policy changes that increased fears among immigrant families about participating in Medicaid and CHIP. These changes eroded some of the previous gains, particularly among Hispanic people.
The COVID-19 pandemic has highlighted and compounded the underlying health disparities. For instance, during the first few days of the pandemic, cities witnessed wealthy residents moving out of the urban areas. For low-income groups, this wasn’t an option. In addition, this same group is overrepresented in frontline work and essential jobs, meaning they’re at higher risk of being exposed to the virus. They’re also at increased risk of experiencing serious illness if infected due to higher rates of underlying health conditions and increased barriers to testing and treatment due to existing disparities in access to health care. In addition, data shows that Black and Hispanic people are less likely than white people to receive a COVID-19 vaccine. One reason this is happening is the digital divide because lack of internet access makes it more challenging to secure appointments. Beyond the direct health impacts of the virus, the pandemic has taken a disproportionate toll on low-income individuals’ financial security and mental health, and well-being. They’re more likely to have lost a job or income and have trouble paying for basic living expenses, such as mortgage/rent or food. Given they might have lost their job, these individuals are likely to see losses in insurance coverage.
Obviously, addressing these inequities would help mitigate the impacts of the COVID-19 pandemic, but it could prevent further widening health disparities. The Biden administration has identified racial equity, including health equity, as a key priority. Immediately after taking office, President Biden issued a series of executive orders and actions focused on improving health equity. Some focused equity as a priority for the federal government broadly and others as part of the pandemic response and recovery specifically. One Executive Order was Ensuring an Equitable Pandemic Response and Recovery, which was designed to address the disproportionate and severe impact of COVID-19 on communities of color and underserved populations. Another, the COVID-19 relief American Rescue Plan Act, provides new funding to support COVID-19 vaccination and other public health efforts. Through this funding, the US Department of Health and Human Services (HHS) is investing nearly $10 billion to expand access to vaccines and better serve communities of color, rural areas, low-income populations, and other underserved communities. A different Executive Order, called Strengthening Medicaid and the Affordable Care Act, established a Special Open Enrollment Period for the Health Insurance Marketplaces and directed federal agencies to review policies and practices to ensure they support access to health coverage. The Department of Homeland Security issued a statement stating that regardless of immigration status, all individuals should receive the COVID-19 vaccines. It went on to say the agency would not carry out enforcement operations at or near healthcare facilities, except in the most extraordinary circumstances. The CDC declared racism a serious threat to the public’s health and remarked that it would lead efforts to confront systems and policies that have resulted in the generational injustice that has given rise to racial and ethnic health inequities.
Even though the federal government has taken steps to tackle health inequality, far more needs to be done, both within and beyond the healthcare system. This should include prioritizing equity across sectors, providing resources to support efforts, increasing data availability, supporting and building on existing community strengths and resources, and establishing incentives, accountability, and oversight for equity. To accomplish this, partnerships across multiple sectors, like transportation, housing, education, and law enforcement, must be achieved. One example of this would be integrating legal services with health services. When this is done, it’s possible to address some of the underlying determinants of ill health, such as discrimination, violence, and lack of housing, rather than just the physical symptoms. Effective referral networks and follow-up are essential components of the process.
Another aspect that is gaining ground is the increased focus on social justice in medical education. For instance, the Liaison Committee on Medical Education (LCME), the federally recognized accrediting body for medical education programs, requires that schools address societal problems and healthcare disparities in their curricula. Essentially, if future physicians understand medicine and healthcare delivery within a social context and accept responsibility for working effectively with appropriate teams, the best possible outcomes will be more likely. The key concept is that an individual’s environment has a significant impact on their health. Here is where physicians have an opportunity to be leaders and take an active role in advocating for things, such as better education and economic equality, that are directly linked to health. The only way this will work is by understanding where people are coming from. When you tell someone they need to eat fresh veggies and have healthy diets, but they live 20 miles away from the nearest grocery store, how will they do that. Who has the gas money to drive 40 miles round trip? By realizing the larger context, physicians can provide better care and advocate for other essential services. The good news is that on medical school campuses across the country, students are beginning to take an active role in addressing social injustices. At Yale, medical students formed the Yale Healthcare Coalition and launched the national #ProtectOurPatients campaign to oppose the repeal of the Affordable Care Act and advocate for a bipartisan approach to improving the law. The campaign has gained nearly 5,000 supporters from 150 medical schools across the country.
There’s no question that racism, socioeconomic inequality, gender discrimination, and hate have negative consequences for health. To improve the health of those affected by it, we need to tackle these concepts at their core. Poor population health is the result of deficient public policy and systemic oppression. We must remember that all of our health is adversely affected by inequality. When we cut down health disparities, we improve our nation’s overall health and reduce unnecessary healthcare costs. The easiest way to look at it is there can be no significant positive health outcomes without social justice. Since the population is becoming more diverse, with people of color projected to account for over half of the population by 2050, we must address health disparities for all of our sakes.