The effects of systemic racism are visible throughout the health care system and in the disproportionately negative health outcomes among communities of color. Black Americans remain the least healthy group.[i] Black patients fare significantly worse than whites in the categories including infant mortality and neonatal health; [ii] HIV/AIDS; cardiovascular disease; cancer screening and management; adult and child immunizations; diabetes; asthma; end-stage renal disease;[iii] nutritional risk; breast cancer; as well as anxiety, depression, and substance misuse.[iv]
There are a variety of factors, or social determinants, that play a role in driving these inequalities in health. Conditions of the social environment are shaped by how the political and economic systems distribute resources, and these conditions contribute as much or more to health outcomes as one’s DNA. Social Determinants of Health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. [v]
Access to care is critical. Across the US we find that 11.4% of African Americans and 20.0% of Hispanics lack any form of health insurance. In North Carolina, those numbers are even worse with 13.6% of African Americans and 32.0% of Hispanics uninsured. Health care access and insurance coverage were major factors that contributed to racial and ethnic disparities before the Affordable Care Act (ACA). Though disparities in access to insurance have been reduced significantly as a result of ACA implementation[vi] research continues to show that health care access especially among minority communities lags and health insurance discrimination occurs.[vii] Recent surveys have shown a strong perception of discrimination in health care among African American respondents.[viii] Studies have clearly demonstrated inferior care received by Black patients in doctors’ offices; disparities in cardiac care, where Black patients are less likely than white patients to be prescribed certain cardiac medications;[ix] less access to curative surgery for early-stage lung, colon, or breast cancer; and higher rates of syphilis in counties which exclude Black professionals from boards of health and county commissions.[x]
Where communities of color are located plays an important role in health disparity. Many studies have shown that communities of color are more likely to experience place-based environmental health hazards such as poor air quality, [xi]hazardous waste[xii] and pre-regulatory landfills,[xiii] pesticide use and toxic chemical releases, [xiv] and often lack safe recreational areas.[xv] They are also more likely to live in areas that are considered food deserts,[xvi] medical deserts,[xvii] pharmacy deserts, [xviii]and in communities with persistent poverty and high rates of social vulnerability.[xix] Researchers have offered overwhelming evidence that Black people receive a lower quality of health care than whites, have less access to care, and have worse health outcomes –even when controlling for income and other factors unrelated to race. This racial dimension of health equity is manifested across all health categories.[xx]
Solution #1: Increase healthcare access among LMI communities
- Expand Medicaid in Non-Expansion States like NC.
- Promote local health system and provider networks.[i]
- Provide insurance to working poor who fall into the coverage gap.
- Expanded funding for Federally Qualified Health Center (FQHC).
- Develop community health worker, health navigator, and home visitation programs.
Solution #2: Address Social and Economic Factors contributing to poor health outcomes
- Provide or expand family and social support systems of care.
- Address community safety as public health issue.
- Expand resources to maternal and child health programs.
- Promote Livable wage advocacy and raising minimum wages.
- Expand availability of healthcare and healthy foods in HRSA identified Medically Underserved Areas and USDA designated Low Income/Low Food Access neighborhoods.
Solution #3: Improve physical environments in which people live
- Treat air quality and pollution as environmental justice issues.
- Develop more stringent mitigation strategies to reduce emissions and toxic exposures in LMI areas.
- Better assess drinking water quality, especially in pre 1980s homes and in neighborhoods with aging infrastructure.
- Involve local residents in LMI neighborhoods in development of remediation plans for Pre-Regulatory Landfills (PRLFs) and other environmental hazards.
- Provide more transportation choice and transit access in LMI communities.
- Expand HUD lead-safe housing and healthy homes programs.
Download the printable Research, Policy, and Impact Agenda Part 3 Reducing Disparities in Health due to Social Drivers
[i] See https://guilfordccn.org/provider-outreach-program/
[i] Noonan, A.S., Velasco-Mondragon, H.E. & Wagner, F.A. Improving the health of African Americans in the USA: an overdue opportunity for social justice. Public Health Rev 37, 12 (2016). https://doi.org/10.1186/s40985-016-0025-4
[ii] Testa, Alexander and Dylan B. Jackson. 2021. “Race, ethnicity, WIC participation, and infant health disparities in the United States.” Annals of Epidemiology. 58: 22-28.
[iii] Bediako, Shawn M. and Derek M. Griffith. 2007. “Eliminating Racial/Ethnic Health Disparities: Reconsidering Comparative Approaches.” Journal of Health Disparities Research and Practice. 2(1): 49-62.
[iv] Williams, David R. and Selina A. Mohammed. 2009. “Discrimination and racial disparities in health: evidence and needed research.” Journal of Behavioral Medicine. 32:20-47.
[v] Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. 2022. “Social Determinants of Health.” https://health.gov/healthypeople/priority-areas/social-determinants-health.
[vi] Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A. N. (2016). “Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act.” Medical care. 54(2), 140–146. https://doi.org/10.1097/MLR.0000000000000467
[vii] Xinxin Han, Kathleen Thiede Call, Jessie Kemmick Pintor, Giovann Alarcon-Espinoza, Alisha Baines Simon. (2015). “Reports of Insurance-Based Discrimination in Health Care and Its Association With Access to Care”, American Journal of Public Health 105, S3:S517-S525. https://doi.org/10.2105/AJPH.2015.302668
[viii] Sills, S., Rich, B., DiMattina, M., Su, H., Gruber, K., (2021). “Dan River Health Collaborative Health Equity Report 2021.” Report Submitted to the Danville Regional Foundation. https://chcs.uncg.edu/dan-river-health-equity-assessment/
[ix] Thomas, Stephen B. and Erica Casper. (2019). “The Burdens of Race and History on Black People’s Health 400 Years After Jamestown.” American Journal of Public Health. 109(10): 1346-1347.
[x] Thomas, Stephen B. (2001). “The Color Line: Race Matters in the Elimination of Health Disparities.” American Journal of Public Health. 91(7): 1046-1048.
[xi] Morello-Frosch R, Jesdale BM. (2006). “Separate and unequal: residential segregation and estimated cancer risks associated with ambient air toxics in US metropolitan areas.” Environ Health Perspect.;114(3):386–393.
[xii] Mohai P, Saha R. (2007). “Racial inequality in the distribution of hazardous waste: a national-level reassessment.” Social Problems. 54(3):343–370.
[xiii] Sills, S. & DiMattina, M. (2021). “Geospatial and Statistical Analysis of Statewide Landfills in NC.” unpublished white paper and presentation as part of the Bingham Park Environmental Justice Research Project.
[xiv] Lara Cushing, John Faust, Laura Meehan August, Rose Cendak, Walker Wieland, George Alexeeff, (2015). “Racial/Ethnic Disparities in Cumulative Environmental Health Impacts in California: Evidence From a Statewide Environmental Justice Screening Tool (CalEnviroScreen 1.1)”, American Journal of Public Health 105, 11:2341-2348. https://doi.org/10.2105/AJPH.2015.302643
[xv] Moore LV, Diez Roux AV, Evenson KR, McGinn AP, Brines SJ. (2008). “Availability of recreational resources in minority and low socioeconomic status areas.” Am J Prev Med.;34(1):16–22
[xvi] Weinberg, Z (2000) “No place to shop: Food access lacking in the inner city.” Race, Poverty & The Environment 7(2): 22–24
[xvii] Carr, Brendan, Bowman, Ariel, Wolff, Catherine, Mullen, Michael T, Holena, Daniel, Branas, Charles C., Wiebe, Douglas 2017. “Disparities in Access to Trauma Care in the United States: A Population–Based Analysis.” Injury 48(2):332–8.
[xviii] Wisseh, C., Hildreth, K., Marshall, J. et al. (2021). “Social Determinants of Pharmacy Deserts in Los Angeles County.” J. Racial and Ethnic Health Disparities 8, 1424–1434 https://doi.org/10.1007/s40615-020-00904-6
[xix] Ibraheem M. Karaye, and Jennifer A. Horney. 2020. “The Impact of Social Vulnerability on COVID-19 in the U.S.: An Analysis of Spatially Varying Relationships.”American Journal of Preventive Medicine 59: 317-325 https://doi.org/10.1016/j.amepre.2020.06.006.
[xx] Smedley, Brian D., Adrienne Y. Stith, and Alan R. Nelson, eds. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington: The National Academies Press