From process to outcome: working toward health equity

The outcome of a health-care treatment depends on the social conditions, resources and historical policies where the patient lives as well as a variety of other factors. Aletha Maybank, chief health-equity officer and senior vice-president at the American Medical Association (AMA) in Chicago, Illinois, describes how her career in health-equity work required a critical analysis of the processes that drive inequity, and gives advice for those interested in working in the sector.

How did you get into health-equity work?

During one of my two residencies after graduating from the Temple University School of Medicine in Philadelphia, Pennsylvania, I was offered a job to start an Office of Minority Health in Suffolk County, New York. I stepped into that role in December 2005 and worked there for three years. My colleagues and I worked to create opportunities to raise awareness of the inequities and disparities that existed in the county, which were often invisible. I committed my time to forming and strengthening our relationships with people from across the county: in schools, community- or faith-based groups, social-service organizations and small businesses, to name a few. We wanted to create spaces of collaboration, trust and partnership. I came to these spaces with no agenda. I wanted to listen to and understand the needs and priorities of the community.

That job was my entry into health-equity work. But my interest in the field started as a natural-sciences undergraduate student at Johns Hopkins University in Baltimore, Maryland, where I took courses at its School of Public Health, including one on Native American health. After graduating, I did a master’s degree in public health at Columbia University in New York City.

How do you define health equity?

The definition I tend to use is ensuring that all people have the conditions, power, resources and opportunities needed to achieve optimal health. For me, the process of achieving health equity comes down to three things. The first is valuing people equally. The second is recognizing and rectifying the historical context of the injustices, including the decisions, policies and practices that produced them. The third is looking at how to provide resources according to a person’s needs and strengths.

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Unfortunately, health-outcomes data continue to show how inequitable systems and institutions are. In the United States, these data include rates of infant mortality, breast-cancer mortality, fire-arm injury, chronic disease, depression and SARS-CoV-2 transmission, as well as life expectancy.

For example, infants born to Black mothers have death rates that are much higher than average, and breast-cancer mortality rates reveal statistically significant differences by race¹. The current average life expectancy at birth for Black people is 70.8 years, for American Indian and Alaska Native individuals, it is 65.2 years, and for white people it is 76.4 years (these racial categories do not include people with Hispanic ethnicity).

How do personal experiences affect health equity?

It is not sufficient to measure only health or disease outcomes if we want to repair the institutional and societal systems, processes and policies that produce health inequity. The core of how we learn about injustice in the United States and worldwide is through the human experience. Personal and community stories are data, too.

While I was serving as the assistant commissioner at the New York City Department of Health and Mental Hygiene, there was a push across the city to build infrastructure to support the increase in cycling. Cycling was assumed to be a priority issue for many Black and brown communities, but the reality was that community members were advocating for more pressing matters. When the city started building bike lanes, the disconnect was palpable. Many were concerned that bike lanes would increase traffic, so idling cars would cause more air pollution, exacerbating health conditions such as asthma. No one in the community was consulted or given notice by the city before the bike lanes were installed.

The way in which this effort was designed and implemented serves as a great example of how equity is also in how we do things. Although we were able to provide education and programming around safe biking and the need for a greener city, this experience informed our process for future initiatives. Meaningful community engagement needs to be the first step of any strategy. Creating space for conversations is an important facet of planning, but most crucially, they can serve as an opportunity to listen to the concerns of community members.

How do you provide resources based on strengths?

A strength-based or asset-based approach, which focuses on the strengths already present in communities, shifts our entire paradigm from one of ‘what’s wrong and making people and communities sick?’, to ‘what’s working and making people reach optimal health and communities thrive?’. It moves us from systems of sickness to ones of well-being. The deeper reality is that people and communities that have been historically marginalized, colonized and disinvested in are still here and surviving as a result of their resilience, power, compassion and empathy. People studying how to advance equity need to accept, acknowledge and study this truth.

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A great example is the Black Progress Index, which describes the social conditions and resources in places where Black people have the best health and well-being. It was published in September 2022 by Andre Perry, an economist at the Brookings Institution, a non-profit research and public-policy organization in Washington DC. It is a collaboration with the National Association for the Advancement of Colored People, a civil-rights and social-justice organization in Baltimore. The index shows that wealth, family health, safety, environmental quality and social and human capital (as measured by educational attainment, geographical diversity of friend networks, levels of religious affiliation and the share of foreign-born Black residents) contribute to Black life expectancy. We need more of this.

How do you work towards health equity in your current role?

My role centres around managing change in organizations and transforming institutions to be more equitable, building on my past experiences. It entails engaging with institutional leadership and normalizing conversations around power and privilege. It is imperative that we don’t lose sight of and hope for our visions of an equitable and just system. Equity can be achieved only when we accept that all people are born equal. Although most would agree that they accept this, we have not built a system that reflects this. For an institution to be equitable, there needs to be a commitment to embedding equity across its entire structure. There needs to be a commitment to reckoning with past and present harms.

For example, to help physicians understand the root causes of health inequities, the AMA produces educational content, working in partnership with academic medical institutions and organizations. In February, we launched the National Health Equity Grand Rounds, a virtual webinar series for critical, complex and urgent conversations about advancing equity in medicine. We did this in collaboration with a variety of organizations, including the Accreditation Council for Graduate Medical Education in Chicago, RespectAbility in Fredericksburg, Virginia, and the US National Center for Interprofessional Practice and Education.

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The series highlights the initial causes of present-day health inequities by tracing the social, economic, political, geographical and environmental forces that shaped opportunities for health in the United States. These quarterly conversations are free and open to everyone.

Over the past year, we have also expanded our health-equity-related content on the AMA EdHub, an online learning platform for health education. It now includes modules on the basics of health equity, the historical foundations of racism in medicine and advancing equity through quality and safety.

How can people prepare themselves for health-equity careers?

A commitment to understanding the impacts of racism and other forms of oppression on health and health systems is critical. To promote reconciliation and racial healing, we must reckon with the US medical system’s historical roots in scientific racism and eugenics movements. For instance, early in my career, I looked at Camara Phyllis Jones’s work around racism at the US Centers for Disease Control and Prevention and read Harriet Washington’s 2006 book Medical Apartheid. I also give credit to W. E. B. Dubois, who wrote The Philadelphia Negro in 1899, pioneered talking about the context of race in health.

We need to recognize and disrupt dominant and malignant narratives that are pervasive in health care, which often blame people for their own health conditions and circumstances and reinforce the false ideas of a hierarchy of value based on gender, skin colour, religion, ability and country of origin. We must build our collective skills and courage to speak up against discrimination, bias and injustice when we see it, and work together as allies and co-conspirators for creating the transformation we need. And finally, we must rest. Rest is radical. We should not sacrifice our mental, physical and spiritual health to advance the mission of health equity.