How to Advocate for Racial Health Equity

A Note To Readers:

When discussions turn to racial health equity too many healthcare-related professionals - practitioners, researchers, academics, social workers, and similar types, including those who claim to support equity - habitually reach for abstraction, obfuscation, or empty and diverting rhetoric of every type...if they dare address it at all. HB's Fearless is therefore publishing the following guide as a needed public service. I reference North Carolina because that is where I live, but the basic assertions are without limit.

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Approach

Racial health equity strategy should demonstrate awareness of the momentous shifts now taking place in the structure and delivery of healthcare services by distinguishing between historic and currently observable inequities, while also identifying the potential for emergent new forms of bias as the system evolves and transforms.

Framing

The strategy should explicitly acknowledge that American healthcare is restructuring. It is decentralizing—shifting from a focus on residential hospitals and institutions to an accelerating reliance on home-based services for both acute care recovery and long-term care. This shift has important implications for patients with serious illnesses and chronic conditions and it has the potential to export already deeply entrenched institutional biases to the emergent home and community setting.

History of Racial Discrimination and Bias

The American healthcare system has a well-documented history of racial discrimination in every institutional aspect: exclusion of minorities and other marginalized groups from high-level administration, management, and decision-making; bias in medical research; lack of access to basic care; differential quality of care; lack of diversity in medical training; abusive surgeries and procedures; lack of investment in minority serving health infrastructure and facilities; lack of culturally appropriate communication & outreach; bias in the development of technology tools and device design; lack of inclusion in ownership of commercial healthcare enterprises, etc.

• In addition, North Carolina, like other former slave-owning southern states, for decades imposed racist public health policies on its Black population, resulting in about 300,000 African American citizens now over the age of 60 who are survivors of Jim Crow healthcare discrimination with generational health profiles shaped by that experience.

Approach to Improving Health Equity

Any approach to improving health equity in North Carolina must acknowledge racial inequity as being endemic to the state’s healthcare system.

• In other words, racial inequity is a given—inequitable treatment is the normal state of things in North Carolina’s public health system.

The approach must also highlight healthcare as a publicly funded enterprise, although many of its functions and services reach the public through private sector providers, thus obscuring the public origins of the actual funding.

• In other words, the healthcare system is an actively discriminating industry creating enormous harm and suffering—particularly in marginalized communities— that is funded in the main with public dollars.

The approach should condemn racial bias in healthcare as contrary to law and intolerable, but especially egregious in a vital service such as healthcare that is funded with public dollars.

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"Healthcare is an actively discriminating industry

that is largely financed with public dollars."

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Methodology for Advancing Health Equity

Advocacy for racial health equity should embrace an existing and widely used standard (by government, corporate, and philanthropic sectors) as it seeks to (1) identify and publicize specific forms and instances of care bias; then (2) propose cures for those specific forms. That standard is so-called “evidence-based” criteria and research.

• There is already a great deal of “evidence-based” research identifying specific discriminatory behaviors, rules, practices, protocols, impacts, and outcomes in many aspects of healthcare, so much so that the AMA has declared racism to be a public health threat and industry associations have publicly acknowledged racially biased practices. Existing research and public pronouncements exposing healthcare bias provides a starting point for equity work.

This existing body of research should become the basis for public outreach and education, as well as advocacy intended to bring near-term relief to victims of healthcare bias. In implementing this activity an advocacy organization should prioritize the following:

• Intentionally expand existing membership or participation to include a broad range of voices, opinions, and expertise, especially from underrepresented social strata and cultural groups.

• Prioritize equity criteria, metrics, and values in appraising every aspect of healthcare system performance.

• Convene forums, conferences, retreats, and colloquia to create partnerships and collaborations with academic and research institutions—particularly Historically Black Colleges and Universities—advocacy groups, and representative community-based institutions, to raise awareness of systemic healthcare bias, and foster discussions aimed at identifying innovative, creative new research models & initiatives that produce measurable actions to eradicate bias.

• Engage government officials, policy makers, regulators, industry leaders, and other executive stakeholders in meaningful discussions that definitively establish the existence of specific forms of bias within their domains of authority as well as adopt concrete metrics for use in measuring bias reduction across the landscape of healthcare services.

Adaptation to System Restructuring

The above narrative relates to addressing healthcare bias as it exists in the current hospital and institutionally focused healthcare environment, but that model is rapidly transitioning to a form much more reliant on home-and-community-based care. As equity advocates address bias within the existing, declining system, they should also look ahead, anticipating and preparing for a much more decentralized model of care delivery and intensified competition for healthcare resources, a competition in which minorities are disadvantaged at the outset. These are some things to consider:

• Today’s US society is demographically very different from what it has ever been in the country’s history. The population will continue to become more heterogeneous. This is a culturally pluralistic society, and pluralism must be the guiding principle in developing home-and-community-based healthcare policies.

• The evolving reliance on home-and-community-based care essentially inverts the existing healthcare model. Protocols and cultures designed for centralized, institutional care must be adapted to the varying care capacities, practices, norms, and preferences of distinct communities and their constituent households. Cultural familiarity, authenticity, and native control will be key to achieving local service penetration, acceptance, and effectiveness, without which improvements in racial health equity will not be achieved.

• Historic discrimination in economic opportunity, housing, education, etc. have resulted in African American communities that lack native institutional and entrepreneurial infrastructure to deliver services required under a home-and-community-based healthcare model. Investments to create competitive native infrastructure in minority communities must be made to ensure equality of access to healthcare and related services under the decentralized healthcare model.

• The home-and-community-based model of care delivery likewise will depend heavily on remote monitoring, residential adaptation to accommodate programs such as Hospital at Home, and other technology intensive platforms. The lack of technological capacity in historically underserved communities puts them at an instant disadvantage in the home-and-community transition. Addressing the technology gap through infrastructure investments, device access, and technical education must be front and center of health equity advocacy going forward.

• Rigid residential segregation presents a geographic barrier to health equity under the home-and-community-based model. In the near-term residential segregation must be taken as an unalterable given, and specific policies (primarily investment in natively controlled institutional and entrepreneurial capacity) must be implemented to overcome this legacy feature, a relic of the Jim Crow policy era.

• In North Carolina, fewer than 3% of seniors over the age of 60 reside in residential care institutions. That means 97% of seniors are receiving the post-acute and long-term care they need at home, primarily by non-paid family and community-based caregivers. This is particularly true in low-wealth minority communities that lack resources to afford commercial care services. While investments in a direct care workforce may be needed, evidence-based research on the actual impact of commercial workforce investments should be encouraged, including an analysis of the socio/demographic profile of typical beneficiaries of these services. Public investments in all care forms—paid and unpaid—should reflect the universality of impact and equitable benefit of those forms of care delivery.

Implementation

Whatever elements are adopted for inclusion in a strategy to guide health equity advocacy, the next step is always creation of a fully elaborated plan for implementation and a review of the partnerships and collaborations needed to make that happen.

Copyright © 2023 by Harold M. Barnette

Although this document is copyright protected, the author freely grants reasonable use of its contents with proper attribution.