Rishi Manchanda, MD MPH, is the founder and CEO of HealthBegins. Here, he shares his optimistic, realistic, and pessimistic views for the future of racial equity in health.
The current state of health equity in America is quite poor—and that's evidenced by the inequities and the injustices we see. The maternal health inequities impacting Black women. Cancer disparities between predominantly Black and white communities. The lack of access to care in historically marginalized neighborhoods. In America, your zip code is often times an indicator of your health.
But there is a groundswell across the country. People and institutions are paying attention and things are slowly changing for the better.
The optimistic outlook: Change is coming.
Structural racism is clearly a major driver of health inequity. Many healthcare institutions, and researchers in particular, have long been satisfied with simply describing the downstream consequences of inequities. "Oh, there's a disparity in terms of the number of Black men who don't get access to early cancer treatment," or, "There's a disparity in terms of the number of Latino kids who don't have access to primary care," or "There's a disparity in terms of the number of Native American kids who have obesity compared to white kids.”
Institutions are finally beginning to understand the different drivers of health equity: the different ways in which resources, power, and opportunity for healthy living are distributed—or maldistributed. For example, institutions are recognizing structural drivers as they learn how America's history of redlining continues to shape health outcomes and disparities among the patients and communities they serve. And they're being pushed—from outside and within—to acknowledge institutional drivers of health equity, including ways in which their own institution's history of hiring, training, and care delivery has worsened racial injustice.
My optimistic scenario is that institutions continue to invest in health equity and regardless of where you live in the U.S., every community will make demonstrable progress towards improving inequities in ways that are measurable. Which means institutions acknowledging structural racism: Without understanding health equity and the social and structural factors that drive it, institutions are simply unaware of problems and less successful in achieving their goals.
Because of the increasing heat on institutions to improve health equity, I think we'll see, for example, significant improvements in reducing the inequities in maternal health outcomes for Black women and other historically marginalized populations. As health outcomes slowly change for the better, we're seeing strong collaboratives form to advance Black maternal health, using multi-level strategies to address structural and social drivers of health inequities in maternal health outcomes. And we're seeing more institutions working to embed equity across business units and departments—from HR and procurement to quality, safety, and community benefits work.
I'm optimistic that as long as we can continue to hold institutions accountable, we'll be able to continue the march towards greater expansion of rights and greater expansion of justice along the way.
The middle ground: Segmented change state-by-state
I've seen a shift of late. Rather than just identifying the downstream consequences, we are interrogating the upstream drivers of the inequities themselves. The shift from disparities research to inequity reduction is distinct: we are no longer simply describing the effects or the problems themselves, but attempting to understand and address the root causes that created those problems in the first place—the social and structural drivers of health equity. Across the board we are finally seeing people inside healthcare institutions focusing on the why and the what: the root causes and what we need to do when it comes to eliminating health inequities.
If we start understanding that equity and collective action is actually just as much a part of our national identity as mom's apple pie and rugged individualism, then we can start to make room for a different set of expectations for ourselves—and our Institutional leaders are starting to acknowledge the need to change. I'm not foolish enough to think our health outcomes are going to dramatically improve overnight, but I do think we're moving in the right direction.
And I'm not Pollyannaish about the possibilities that these advancements—policy reforms in particular—could be derailed or contested. Because we have a strong countercurrent right now when it comes to reactionary nativist sentiments. So while optimistically I think every community can see health outcomes improve and inequities get eliminated, realistically the ‘political determinants of health' are going to continue to play a major role.
Just look at Medicaid expansion. The evidence shows that expanding access to Medicaid coverage very literally saves lives. Yet some states have expanded Medicaid while other states have not. And why not? Largely because of gerrymandering, redistricting and other political manifestations of structural racism—policies designed to amass power, resources, and opportunities for health for some by denying it to others. So while I do think we'll see a lot of progress in many parts of the country, that progress is going to be unevenly distributed. And it's not going to be unevenly distributed necessarily by race or ethnicity only. It's going to be largely defined and distributed along political boundaries state-by-state and county-by-county. As long as we let exclusionary, nativist and structurally racist policies persist, where you live will continue to have an influence on how long you live.
Pessimistic: Nativist policies will stunt change
Ultimately this comes down to how do we make the work of addressing inequities in health be seen as something beyond a partisan issue or beyond a tribal identity issue. The persistence of inequities is not only harmful to racial minorities and marginalized communities, but it drags everybody down. It actually diminishes us as Americans. Research shows that exclusionary, structurally racist policy agendas—like denying Medicaid expansion—not only severely harms lower-income and Black and brown communities, they also lower life expectancy, overall health, and economic productivity for everyone, including Americans who are white or more affluent. As COVID-19 has taught us, health is not a zero-sum game: I am not made healthier by denying you opportunities and resources for health.
If inequities in the system continue to succumb to this back-and-forth between tribal identities then we have a long uphill battle. We'll be stuck with our current, inequitable status quo.
We need to frame this as a new social contract. We need to force ourselves and our neighbors to think beyond just strategies and policies but a new story of ourselves. The American identity is essentially at question here. Think of it this way: if we can start to see health equity as part of the fabric of what it means to be an American, then we'll be in a situation where we'll actually be able to effect real change. It's not automatic, it's hard fought. And we're making progress. I remain optimistic because—like a growing number of people out there—I'm not giving up on the fight for health equity and racial justice.
Rishi Manchanda, MD MPH, is the founder and CEO of HealthBegins.
