Addressing Racial Disparities In Health Begins Upstream With Racial Equity In Society

This month, the American Medical Association (AMA) officially released an ambitious three-year plan to dismantle structural racism within their organization by addressing past harms and examining institutional roles that uphold these structures. AMA launched this work in 2019, but the events of 2020 and 2021 highlighted the pervasiveness of racial inequity in health care and emphasizing the necessity for such a plan.

AMA’s plan is not just about organizational racism. It is ultimately aimed at reducing the enormous disparities in health status that are intrinsically tied to race and racism. These ongoing health disparities and the ongoing health threat posed by systemic racial inequity were amplified by the COVID-19 pandemic, with Black and Latino populations disproportionally impacted. In fact, a recent study showed 34 percent of COVID-19 deaths were among non-Hispanic Black people, though this group accounts for only 12 percent of the total U.S. population. Furthermore, Black, Latino, and Native Americans are up to two times more likely than whites to have chronic health conditions, such as cancer, diabetes, asthma, and heart disease. While this data is startling to many, it is not surprising to preventive medicine and public health physicians who have witnessed, measured, and fought to disrupt this status quo for years.

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AMA’s plan includes five strategic approaches – each of them critical to advance racial equity. Medical specialty professional societies like mine, the American College of Preventive Medicine (ACPM), should emulate these strategies within their own organizations to assure the entire system of health and medical care moves forward along this critical pathway. As preventive medicine and public health physicians, our specialty is especially well prepared to enact real and meaningful change in the strategic approach to move upstream from our traditional physicians’ roles to address all determinants of health and root causes of inequities. By moving further upstream – treating social and structural problems just like other health issues treated within the doctor’s office – we will begin to treat the underlying causes of racial inequity in the health care system.

When we “go upstream,” we find that while genetics play a part in one’s health, factors beyond one’s control play a far greater role. Neighborhood and housing conditions, and access to fresh fruit and vegetables, transportation, education, and economic opportunities all contribute to one’s overall health. Likewise, access to high-quality health care – including preventive and treatment modalities – is critical. But all these upstream issues are entangled in complex ways to the long history of structural racism in our country. To tackle all of these at once and individually is daunting and unrealistic. But, if all physicians and physician specialty societies begin to take the steps we can take, we will begin to disrupt negative health outcomes plaguing communities of color at a much higher rate than their white counterparts.

Taking these steps will not be easy for individual physicians or our organizations. Like many white people in this country, I struggled to fully understand how I benefitted from the inherent privilege of our society. Today, I better understand the gaps in my education and experience, the mistakes I unknowingly made, the limitations of my attempts at reconciliation, and the structural barriers to anti-racism I encountered within the organizations I trained and worked. The AMA’s strategy is an important guide for us as physicians, particularly those of us in public health and prevention, to seek the truth of our own, and our organizations, past harmful actions. Further, we must use our expertise, opportunities, and positions to reconcile those harms and break down our health organizations’ ongoing structural and systemic biases.

As a preventive medicine physician, I rely on data to drive my decisions. The data on this is clear: racism is a serious public health issue because it is the underlying cause of illness and injury for so many. To “treat” the effects of racism we need to look beyond just treating illness, to preventing illness and the root causes of those illnesses. We need to disrupt upstream structures and systems. We need preventive medicine and public health specialists for the essential skills our training brings to tackling these issues. Preventive medicine screenings and programs that focus on prevention, vaccination, and lifestyle will address chronic disease such as heart disease, diabetes, and some cancers. Making them more available in urban and rural neighborhoods will offer increased access to care among communities that have long gone without. Eliminating food deserts, addressing housing quality and availability, assuring excellent education, and improving transportation options will go even further to reduce health risks. Childcare centers, zoning regulations, and clean water and air regulations will create the social and physical environments that nurture rather than consume health.3

The American College of Preventive Medicine (ACPM) is urging policymakers to address health disparities by enacting and funding the programs and policies that matter: end overtly racist policies, build a public health and health care infrastructure that eliminates systemic racism, and go as far upstream as possible to address the racism built directly into our housing, educational, and environmental systems. Establish policies and programs to collect the needed data to make good decisions and establish policies and programs to use the data to fund and build the bridges we need to close the health divide. Without a doubt, there is no possibility of promoting prevention and eliminating disparities without first eliminating racial injustice at the foundation. As Canadian philosopher Matshona Dhliwayo wrote, “It is the root that gives the tree strength, not its branches.”

Our nation is at a crossroads, but one thing is clear – the health of our country depends on the health of all individuals in it, regardless of income, gender, or race. ACPM is committed to doing our part to promote and advance health and safety for all populations. On a community level, there are several options that can be taken to maintain support (the CDC has listed them out here). As preventive medicine specialists, I call on all my colleagues, more than 10,000 across the country, to continue to bridge the gap by encouraging policymakers to strive to eradicate structural racism and inequalities in our cities and states.

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