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September 21, 2020

In Pursuit of Health Equity: An Evolution in Healthcare

In Pursuit of Health Equity: An Evolution in Healthcare

At the crossroads of storylines between the COVID-19 pandemic and summer-long protests for racial justice, one health topic remains painfully relevant:

Health equity.

Between an increased awareness of inequities in our societal structures or our understanding of the disparities in how COVID-19 has affected Black and Latino populations, the need is in focus.

Consider:

  • For COVID-19, 13.6% of the reported COVID-19 deaths in Indiana are identified as Black or African American, even though the Black population make up 9.8% of Indiana’s population.1
  • In 2017, Black babies in Indiana were more than 2.5 times more likely to die in the first year of life than white babies. As far as the disparity between Black and white babies, it’s a trend that’s largely remained unchanged in recent years.2
  • In different Marion County ZIP codes, life expectancy ranges from a low of 70 years to a high of 86 years.3
  • Also in Marion County, people living in high-poverty areas were more likely to have environmental hazards nearby and also face chronic disease inequities.

So, what should be done? And how does a healthcare system like IU Health address inequities in health?

Health equity, according to the Robert Wood Johnson Foundation, means that “everyone has a fair and just opportunity to be as healthy as possible.” And this means “removing economic and social obstacles to health, such as poverty and discrimination.”4

Some of our health factors are driven by genetics or behavior. But much of our health is driven by the social and economic factors around us – the determinants of how and where we live, work and play – and their unequal distribution among people and within communities.

To get to that place of equity is complex. It means addressing racism and other forms of oppression – from societal levels all the way down to healthcare settings. It means peeling back the layers and focusing on root causes within community health.

All of it requires coordination, partnerships, data-driven action, and boots-on-the-ground work.

“How do we figure out how we dismantle all the ways that these inequities have been created through decades, specifically in health and a health system?” IU Health Community Outreach & Engagement Director Brenda Biggs said. “That’s going to take some time, and it’s going to need to be an intentional effort.”

Understanding Root Causes

Health equity is not achieved if health disparities continue to cut across people by race, ethnicity, gender, sexual orientation, and other excluded or marginalized groups and determinants of health including housing, jobs, food, and education.

In fact, for health issues in Indiana, oftentimes poverty – namely, Hoosiers who struggle to get by, is a key underlying determinant of health that influences health and unfairly impacts certain populations.

Dr. Karen Amstutz, vice president of Community Health for IU Health, has been leading many community health initiatives by researching, strategizing and developing evidence-based programs to address these community health needs.

"If you look at the root cause of many of these health outcomes, there’s a poverty of resources and opportunity,” Amstutz said. “Individuals and families experience chronic stress which is toxic ... stress is additive and has an impact on adult health."

And often health inequities overlap and span different communities and determinants of health. “It’s intertwined,” said Lori Satterfield, program manager on the Community Outreach and Engagement team. “You’re going to find individuals impacted most by inequities are low-income and racial and ethnic minority communities. As IU Health is outreaching outside the walls of our hospitals, we’re really looking at how we address inequities – it’s part of fulfilling our vision and values.”

The Community Outreach & Engagement team at IU Health works on identifying and addressing these issues through its community benefit program activities and partnerships.

Marcie Memmer, a program manager for the team, said, “What we’re learning is there’s some really bad reasons that there are differences in how disease is impacting people. When you start peeling away those layers, you find, it’s poverty, it’s housing, it’s transportation, it’s food, but then you’re also finding that it’s racism and other forms of discrimination and an unfair distribution of resources. We’re starting to get into things impacting health that may be uncomfortable for people to talk about.”

Finding the Right Answers

The challenge for addressing health equity for a healthcare system, government or any organization: How do you address these issues? If health equity means everyone has a fair and just opportunity to be as healthy as possible, how is that achieved?

“The big answer is policy change and multi-sector collaboration,” Amstutz said.

Take the lack of robust paid sick leave policy, for example. That could leave lower income workers more likely to go to work despite COVID-19 concerns, Amstutz said. In turn, this may drive up infection rates or unemployment and widen long-term inequities for people with lower income jobs.

This leads to a concept of health in all policy, an effort to include health and equity considerations in policy across all sectors of society.

Biggs said there’s an element that all work that is done can be through the lens of health equity.

“Equity in all policy means it really is interwoven through all of the work, so when we’re looking at things, we’re making sure it is present for anything and everything,” Biggs said.

So there are solutions that can be applied at the local or organizational level. Whether it’s being an advocate and voice as a state healthcare leader or being community partners to organizations committed to the shared mission of IU Health. That can mean buying locally, investing locally and hiring locally.

But Amstutz said there’s also a lot of work still to be done: For Hoosiers, what are the biggest drivers? Is it housing? Income inequalities? Is it a voice in social policy?

IU Health is taking steps to identify and address health inequities. One way the Community Outreach & Engagement team is doing this is through its work with community members and partners, including the community health needs assessments. These reports are published every three years and seek to identify priority health needs and understand health disparities in each of the communities that IU Health serves.

In the most recent 2018 cycle, most communities determined that behavioral health; obesity; access to care; determinants of health such as poverty, food access, and housing was a key priority. And those reports, full of information and data, are a wealth of knowledge for IU Health. It allows IU Health to partner with organizations or help fund and support initiatives that affect change in their communities. For example, in 2019, more than $900,000 was awarded to 24 organizations to address the priority community health needs and determinants of health for Marion County residents including those experiencing health disparities.

“It’s really all there to some extent as far as what’s happening in our communities, why it is happening,” Memmer said. “The reports are rich information for a lot of reasons. It helps us decide to invest in organizations meeting social needs such as Gleaners. It helps IU Health Foundation write grants and focus the narrative of where the need is, it helps other funders and community partners focus on specific needs and align resources.”

An Evolution to Equity

Ensuring health equity might be seen as a risky investment or a drop in the bucket. Sometimes the patients being served are the highest cost. There’s not enough funding to go around to all the worthy community partners.

Biggs said the conversation has shifted in the past several years with a greater awareness of the root causes. Amstutz said she likes the phrase “upstreamers” – moving farther and farther upstream to address the issues impacting communities in Indiana. This also means looking at strategies on a continuum that move from programs to policy, environment, and system changes.

It’s an ongoing conversation. IU Health has made a goal of seeing Indiana become one of the healthiest states in the nation.

“As we evolve and start to make better connections with root causes, it’s become more apparent that if people don’t have those basic social needs met, and in a manner that’s equitable to everyone, everything else falls apart,” Biggs said.

IU Health’s goal will only be fully reached if all people have a fair and just opportunity to be healthy in our state.

References:

  • Indiana State Department of Health. Indiana COVID-19 Dashboard. 10 Sept 2020.
  • Indiana.gov. 2019 September. Indiana State Department of Health. 1 Sept 2020.
  • Bowman, Elizabeth, Elinor Hansotte and Zuker, Jennifer. Health Equity 2018: The State of Health in Marion County. Indianapolis: Marion County Public Health Department, 2018.
  • Braverman, Paula, et al. What is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.

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