Health Equity

Why it’s time to address the root causes of health inequity

Andis Robeznieks , Senior News Writer

There is growing awareness that the health inequities seen during the pandemic were not created by COVID-19 but were already in existence, and there is increasing recognition that structural racism is at the root of these inequities.

AMA Equity Plan 2021-2023

Read about the AMA’s strategic plan to embed racial justice and advance health equity.

What can be done to take advantage of this new recognition to bring about positive changes to reduce and ultimately eliminate these inequities?

Leon McDougle, MD, MPH, the president of National Medical Association, suggested that—from a policy and legislative standpoint—one major action could be expanding Medicaid eligibility in the 12 remaining states that have not yet done so under the Affordable Care Act.

The AMA encourages all states to expand Medicaid eligibility up to 133% of the federal poverty level. Learn more about the AMA’s 2021 plan to cover the uninsured.

“We have an answer, a vehicle to help get those uninsured people insured,” Dr. McDougle said. “That should be a priority and focus.”

Dr. McDougle made those remarks during a recent episode of the AMA "Prioritizing Equity" video series that features a panel of experts illuminating the effect COVID-19 has had on communities that historically and contemporarily experienced inequities.



Dr. McDougle, a professor of family medicine at Ohio State University (OSU) College of Medicine and chief diversity officer for the OSU Wexner Medical Center, said there “has been nonstop action” since the start of the pandemic. At the local level, this includes the city of Columbus, the Franklin County Board of Health, and the County Board of Commissioners all declaring racism as a public health crisis.

“What does that mean?” he asked. “It means that we need to take a closer look at the structural factors—from housing to education, to employment discrimination—to offset and counteract this racism.”

It will also require investment in American Indian and Alaskan Native schools, historically Black colleges and universities, Hispanic-serving institutions and institutions that offset homophobia, Dr. McDougle said.

Winston F. Wong, MD, chair of the National Council of Asian Pacific Islander Physicians (NCAPIP), noted how thousands of people had died from COVID-19 before there were any deaths reported among Asian Americans, Native Hawaiians and Pacific Islanders because most states were not disaggregating the data.

His organization dug through state data to identify Native Hawaiians and Pacific Islanders and then pushed state and county officials to identify COVID-19 deaths among those populations, Dr. Wong said.

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These efforts led to finding that, for example, the highest death rates in a five-county region of Northwest Arkansas belonged to a Marshallese Pacific Islander community. Also, in California, it was found that almost one-third of nurses dying were of Filipino descent.

“That's a story that would not have been told,” Dr. Wong said. “There's so much underneath that with regards to why the mortality exists, why it wasn't reported, and what we need to do to apply those lessons relative to the vaccine effort.”

In addition to the pandemic, there is an “overlay” of discrimination that has manifested itself in the growth of violence and hate crimes against Asian Americans and Pacific Islanders. This is not new and has only been fueled since the start of the pandemic.

“The root cause is the continuous narrative of our communities being considered foreigners ... people that are not part of the American fabric,” Dr. Wong said.

The AMA condemned the shootings in Georgia last month that left eight people dead and appeared to target the Asian-American community.

“Early in the pandemic, the AMA highlighted that xenophobic language around the virus threatened to further fuel discrimination and hate crimes against Asian Americans, which were already a significant concern due to longstanding interpersonal and structural racism,” said AMA President Susan R. Bailey. “Racism and xenophobia—in action and in language—must not be tolerated.”

In the spring of 2020, then-AMA President Patrice A. Harris, MD, MA, strongly condemned “xenophobic and race-based scapegoating against Asians and Pacific Islanders in America and against Asian-presenting people.”

Elena Rios, MD, MSPH, president and CEO of the National Hispanic Medical Association, said access to vaccines is an emerging issue of concern, in part, because of the digital divide that gives an advantage to those who own computers.

There are positive developments, she said. These include a growing interest in public health among Latino physicians and funding in the American Rescue Plan Act for the public health infrastructure,  COVID-19 testing, tracing and vaccines, and for scholarship and loan repayments that will help more Hispanics become physicians and nurses—and, in turn, become community role models.

Panelist Mary Owen, MD, president of the Association of American Indian Physicians, noted that the Indian Health Service has been chronically underfunded and there is concern about further budget cuts. She added that the agency’s low salaries make it difficult to attract physicians, causing a high vacancy rate in some areas.

“Our physicians are just looking for some backup,” Dr. Owen said.

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Dr. Owen directs the University of Minnesota Medical School’s Center of American Indian and Minority Health, and she said it’s hard for medical students to fathom what it’s like to live in these conditions.

“No matter how many lectures we give, no matter how many talks like this we have, so many people still don’t understand what it means to live in COVID without resources,” she said.

Panelist Hector Vargas, executive director of GLMA: Health Professionals Advancing LGBTQ Equality, cited a study published by the Centers for Disease Control and Prevention that found LGBTQ+ people had higher self-reported rates for disease and conditions that make them more susceptible to severe COVID-19 outcomes.

Vargas then cited another study that found nonwhite LGBTQ+ people had a 14.3% COVID-19 positivity rate compared with 7.2% for white LGBTQ+ people. During the past year, GLMA has focused on telling the stories of front-line LGBTQ+ health care workers who, Vargas said, risked their lives but are still “subject to firing in the workplace simply because of who they are.”

Systemic and institutionalized racism contribute to inequities across the U.S. health care system. Learn how the AMA works to identify and eliminate inequities through advocacy, community leadership and education.