Health inequity’s no accident, and fixing it will take real purpose

Racism is a public health issue, and AMA policy recognizes it as a serious threat to “the advancement of health equity and a barrier to appropriate medical care.”

The lack of opportunity in historically marginalized communities has produced unjust inequality in terms of education and income that generates undeniable health inequities revealed by the wide differences in life expectancy seen among the residents of ZIP codes that are only short distances apart.

But the poverty in these communities does not show a failure of government efforts to solve problems or the inability of people to lift themselves up, according to medical sociologist David R. Williams, PhD, MPH. He chairs the social and behavioral sciences department at the Harvard T.H. Chan School of Public Health.

“The racial inequities in income and education that matter for life and health do not reflect a broken system,” Williams argued. “They reflect a carefully crafted system functioning as planned, successfully implementing social policies—many of which are rooted in racism.”

Williams made those remarks while speaking at “Righting the Wrongs: Tackling Health Inequities,” a health equity virtual summit hosted by the Hastings Center and co-sponsored by the AMA.

“The inequities we see are not accidents or acts of God, they illustrate, how racism has produced a truly rigged system in the United States and segregation also adversely impacts access to care and the quality of medical care,” Williams said.

He touched on similar points in an Oct. 12, 2020, JAMA Viewpoint commentary on excess deaths from COVID-19 that he co-wrote with Johns Hopkins University School of Medicine researcher Lisa A. Cooper, MD, MPH; and in his widely viewed TED Talk, “How Racism Makes Us Sick.”

Williams cited medical research, including several studies by Tené T. Lewis, PhD, an Emory University epidemiologist who has examined the link between psychological and social factors and the disproportionate rates of cardiovascular disease among Black women.

The studies Williams cited noted the correlation between “everyday discrimination” and coronary artery calcification, higher blood pressure, low birth rates, poor sleep and other negative health impacts.

“I could go on and on—there over 400 studies from around the world documenting the negative effects of everyday discrimination on health,” he said. Such discrimination “at a high level is an independent predictor of premature death.”

Other studies cited included figures showing that Black children were more likely to lose their mothers by age 10, Black parents were likelier  to lose a child by age 30, Black children had higher rates of suicide, and that exposure to racism and negative economic and psychosocial stresses lead to “weathering”—or premature aging.

Learn about the AMA Center for Health Equity and the AMA’s strategic plan to embed racial justice and advance health equity.

Developing a more diverse physician workforce is one solution, Williams said. Others fall under the umbrella of creating “communities of opportunity” that would “minimize, neutralize and dismantle the systems of racism that create inequities in health,” he said.

Among other efforts, Williams touted the development of “purpose-built communities” such as the Villages of East Lake (PDF), an Atlanta development whose programs and design were shown to improve the area’s housing stock, lower the unemployment and crime rates, and boost performance in schools while forming a “cradle to college” pipeline.

There are three necessary building blocks to enable widespread adoption of such proven solutions, Williams argued. They are to:

• Raise awareness “of the challenges that face disadvantaged racial and ethnic populations.”
• Build empathy, because “we need to feel the pain that our fellow human beings are facing based on the policies that we have developed in this society.”
• Build a science base to guide and develop the political will to address racial and other social inequities in health.

Citing U.S. Census data, Williams noted that, while Black and Hispanic people have higher rates of poverty, there are far more white people living in poverty.

“There are almost twice as many poor whites as poor African Americans—so it is about all of us,” he said. “When we develop policies to reverse racial injustice and treat everyone with the dignity and respect that they deserve, it will be beneficial to people of all races.”