Health inequities are no accident. They are the result of deeply embedded policies and systems spawned by structural racism and dismantling them requires a plan with specific and measurable goals that are publicly tracked and shared.
There has been “uneven progress and even resistance” to doing so, however, according to a study by researchers from the Sinai Urban Health Institute and the AMA that was published in the Journal of Racial and Ethnic Health Disparities. The researchers noted that local health departments are well situated to lead such plans but not many are doing so.
They examined formal plan documents and strategies from local health departments with jurisdictions covering the 30 most populous U.S. cities. The plans were evaluated for their focus on health equity and inclusion of specific and measurable equity goals, and an assessment regarding their formal declarations of racism as a public health crisis, organizational structure, and data collection and dissemination practices.
Their findings included:
- 29 cities had a formal public health plan or strategy.
- 25 provided data on racial health inequities.
- 23 had declarations aligned with AMA policy identifying racism as a public health threat.
- About half of the local health departments had positions or divisions focused on racial equity
- 13 had health plans that included racial health equity as a strategic focus.
- 7 had health plans with specific and measurable equity goals.
- 6 described racial health equity as a focus, but had no goals linked to that focus.
“Having an equity-focused plan is an important (arguably necessary) step to advancing equity, but it is not sufficient on its own,” the study says.
Some plans had a focus on health equity, but not specifically on racial health equity.
Washington’s plan, for example, had goals linked to social determinants of health such as raising the high school graduation rate while lowering the proportion of people in poverty. But these goals were not specific to a racial group or aimed at reducing a racial gap, the researchers wrote.
Racism’s threat to public health
The study’s authors noted that it was “disturbing” that seven cities had not declared that racism was a public health threat, but also wrote that, for some of those that did make such a declaration, their efforts were insufficient to make much progress.
Many of the published declarations “lacked specific goals, program or funding related to the issue,” the study says. “Without a commitment to specific racial justice metrics, the antiracism declarations will likely fall short of their intended purpose.”
The researchers highlighted the effort of Marion County, Indiana, which includes Indianapolis, for publishing an equity report that provides historical context, data on social and environmental factors, and a comprehensive set of outcomes by race and ethnicity.
“Where you live affects your life expectancy,” says the 2018 county report. “In different Marion County ZIP codes, life expectancy ranges from a low of 70 years to a high of 86 years.”
Life expectancy was used by the researchers as a measure of population health, with the life expectancy gap between Black and white residents used as an indicator of racial health equity.
Among the cities examined, only El Paso, Texas, had a longer life expectancy for its Black population compared with white residents. In Washington, Black residents’ life expectancy was 12 years lower than for the white population. The city with the next-highest gap was San Francisco, where Black people were expected to live 10.5 fewer years than white people.
Local health departments “must be explicit and intentional in documenting the inequities, prioritizing them for elimination via health improvement plans and strategic resource allocation, implementing multi-level solutions, and publicly tracking progress toward equity,” wrote the authors, who include Fernando De Maio, PhD, the vice president for health equity research and data use in the AMA Center for Health Equity.
This study is the latest by De Maio and colleagues whose research has compared the health and health equity indicators among the 30 most-populous cities. They have also highlighted the progress some cities have made—leading the researchers to conclude that health inequities are not inevitable.
“Our data show that levels of health inequity can vary between cities and can change over time—the problems are structural but not set in stone,” said De Maio, whose previous research has been compiled in Unequal Cities, Structural Racism and the Death Gap in America’s 30 Largest Cities, a book published by Johns Hopkins University Press.
“We can aim for and achieve much more equitable outcomes, and it is heartening to see local health departments in major cities leading this effort—often in collaboration with health systems, community partners and physician leaders,” he added. “Yet this work is far more supported in some places than others.”