Public health leaders reveal basis for race-class health inequities
Public health professionals told how COVID-19 has made obvious the disparities in public health based on socioeconomic position, race/ethnicity, nationality, nativity, immigration, citizen status, age and gender.
Eastern Washington Legislative Conference workshop leaders were:
• Bob Lutz, medical advisor for COVID-19 medical response for the Washington Department of Health, worked eight years with the Spokane Regional Health District (SRHD) until 2020.
• Heleen Dewey, health equity specialist with the SRHD, focuses on racial equity for better health outcomes. She is a member of the Turtle Mountain Band of Chippewa Indians and is also Santee Sioux.
• Amber Lenhart worked with the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and Pew Charitable Trusts in Washington, D.C., and served as the SRHD health policy specialist.
"One's zip code is more important to one's health than one's genetic code," Bob said. "Structural racism undergirds American society. Health begins where we live, learn, work, play and pray.
"Social determinants have impact. The country was built on the backs of slave labor and the lands of indigenous peoples. Marginalization and vulnerability mark populations impacted by structural, avoidable and unnecessary inequities, which result in disproportionate illnesses and hardships," he added. "Health care is a contributing factor. There is racial bias in health care in terms of access and location."
Bob said COVID-19 reflects those inequalities. In the last two months, the Department of Health released data it did not have before. Nationwide data shows significant disproportionality in black, Hispanic and Pacific Islander populations in the number of cases, hospitalizations and deaths.
"When we miss data, we misrepresent the impact of communicable diseases on these populations," he said.
The disparities play out in distribution of vaccines to marginalized people and at risk essential workers. He sees vaccine resistance as an outgrowth of distrust based on historical events, such as the 1932 to 1972 syphilis experiments on African Americans at Tuskegee Institute.
Heleen looked at reasons for disparities in COVID data.
"We see racial disparities in every system, not just health care, but each calls it something different," she said. "In health, it's disparities. In child welfare, it's disproportionality. In juvenile justice, it's disproportionate contact. In education, it's the achievement gap.
"Racism impacts health because of different access to resources, biological responses, chronic stress, increased wear and tear on the body, and more cancer and high blood pressure, making risk of death from COVID higher," said Heleen, noting that interpersonal and structural racism affects decisions in communities, with explicit racism to implicit bias affecting decisions.
"Racism impacts people's biology in that chronic toxic stress leads to some illnesses. The lack of access to resources and living conditions for people of color make them more susceptible to environmental transmission of COVID," she said.
She differentiated between public health and the medical model. Public health focuses on behaviors that impact health—like eating well, being active and not smoking.
"With COVID, many are unable to follow public health guidance because social structures impact their behavior," Heleen said.
A socio-ecological model looks upstream to see that where one lives and works has impact on behavior. Discriminatory beliefs or "isms" in societal structures—racism, classism, sexism—and status—social, economic, immigration, age—affect decisions and social messaging.
"Those isms impact neighborhoods, schools, housing, workplaces and family living conditions, which lead to behaviors," Heleen said.
Biased beliefs lead to policies and practices that lead to disparities that impact communities and have medical consequences.
Public health gives guidance for social distancing, wearing masks and for those exposed to isolate at home, but some communities cannot follow the guidance because they cannot take the time off without losing their job or cannot access unemployment benefits, she said.
"Isms can lead to negative policies and outcomes, as much as behaviors can lead to disease," Heleen said. "We need to change the narrative and policies to empower people whose voices usually are not considered in decisions."
Growing up on the Chippewa reservation, she knows that explicitly racist policies can lead to genocide.
"Racism is also implicit in policies, hidden, but there," she said. "We now have an opportunity to change, but we need to feel, heal and deal so we can surface truths about where we were and are as a country. Now is the time for transformative policies.
"We are all in a global pandemic, but are not in the same boat. Some are in yachts, some are in kayaks and some are treading water. It's a catalytic moment to make changes," Heleen said.
Amber worked 10 years in public health, focusing on policy change to move from inequities.
The U.S. does not have a good return on its investment in health, even though it spends more than other comparable nations, Amber said.
"Health doesn't happen in a doctor's office. Educating people about healthy lifestyles may not work if they are surrounded by fast food outlets and freeways, or live with someone who smokes," she said. "Social, economic and environmental factors lead to outcomes.
Policies shape health inequities for Hispanic, Native American, Pacific Islanders and African Americans.
Amber used an analogy to a tree to show that what drives inequities in the canopy comes from the roots through the trunk and branches.
"A tree's canopy reflects health outcomes like more hospitalizations and deaths," Amber said. "Some have to work even if they are contagious and some live in crowded multigenerational households. Why? Their community infrastructure sets their environment: like workplace policies, housing costs or cultural expectations.
Socio-economic factors include employment status, educational attainment and neighborhood setting.
"Keep asking why, and we see policies and systems at the roots—school discipline, inability to work from home, and housing, transportation and criminal justice policies," she said.
In the groundwater are biases/beliefs: racism, classism, sexism or xenophobia.
"We eliminate inequities by changing policies, systems and environments that create them," she said. "Then we can talk with, educate and lobby decision makers on how policies impact health.
"We can listen to and amplify voices of people with lived experience. They are the experts," Amber said.
For information, email Bob at email@example.com, Heleen at firstname.lastname@example.org or Amber at email@example.com.
Copyright@ The Fig Tree, March, 2021