At the Helm

10 takeaways: How to build true health equity amid a global pandemic

by Christopher Kerns and Amanda Berra

Advisory Board's Christopher Kerns and Amanda Berra provide their top 10 takeaways on the past week of the Covid-19 epidemic, focusing on the vital role that health care leaders play in combating structural racism, during the pandemic and beyond.

Covid-19 weekly webinar extended through June: What health care leaders need to know

1. Even amid Covid-19, it's appropriate for health care leaders to allocate focus on protests against racism—which is also a public health issue

Last week, the United States—like many countries around the world—continued to see Covid-19 death rates trending down. Generally speaking, cautious optimism on the pandemic's trajectory seems warranted, although huge variations remain between cities and regions.  

Even as we continue the battle against Covid-19, it's critical for health care leaders to also address the other issue roiling the nation: the recent deaths of George Floyd, Ahmaud Arbery, and Breonna Taylor, and the resulting widespread protests of racial injustice.  

In the short term, there are several ways health care leaders can help protect protesters' health—and, in doing so, contain the spread of the new coronavirus—including:

  • Donating masks and hand sanitizer to protest organizers, if your organization has sufficient supply;

  • Letting staff volunteer to provide first aid and medical care; and

  • Ensuring clinicians encourage vulnerable patients to find alternative ways to advocate for change, rather than joining in-person protests, given the risks posed by the virus.

In the long term, health care leaders are in a position to take action now on the larger challenge: the public health and clinical issues associated with racism.

2. Moving forward, all health care stakeholders should look at racism and violence through a public health lens

Within any health care organization or community, different people are starting from very different levels of familiarity with the public health and clinical implications of racism. Some people are already experts in this terrain and have been calling attention to the issue for years. Others have been insulated from these issues—and must now come to fully understand the public health implications. (It's OK if you're still getting up to speed yourself; Advisory Board has made available free resources to help.)

3. Health care leaders should think of racism not only as an interpersonal issue but as a systemic and structural issue

For those who aren't familiar with the difference between structural and interpersonal bias, Darby Sullivan, Advisory Board's lead researcher on health equity issues, says that the key distinction is that structural racism emerges from design and structures in institutions.

A structurally racist policy may or may not have been designed with bias in mind. Either way, the policy itself endures, and does not require individuals to be biased, or want to act in racist ways, for the negative impact to continue.

Disparities in Covid-19 outcomes provide many examples of structural racism and its consequences:

  • Higher rates of chronic conditions that make Covid-19 more dangerous;

  • Higher prevalence of adverse social determinants, such as living in low-income communities, having less access to health care, or lacking the social goods that protect health, such as healthy food and stable housing;

  • Being more likely to hold "essential" jobs in health care, transportation, and food supply that prevent people from following social distancing guidelines; and

  • The numerous policies, institutional practices, and legal frameworks that have contributed to the creation and persistence of these conditions over time.

Simply changing interpersonal behavior will not solve these problems. They will require sweeping, fundamental changes in policies, investments, and the practices of many different kinds of institutions.

4. Evidence shows that Covid-19 threatens black lives disproportionately

Sullivan points out that it's no coincidence that protests have erupted in the context of the Covid-19 pandemic—because the pandemic has starkly showcased America's longstanding disparities. 

Black Americans are dying from the effects of the virus at a rate 2.4 times that of white Americans. The economic shutdown is impacting economic stability for everyone, but black Americans especially. And statistically, since the arrival of the new coronavirus, black Americans have struggled more than white Americans to afford essentials—such as food, utilities, and stable housing—that drive health outcomes.

5. Violence, including police violence toward black Americans, is a well-documented public health issue

The consequences of violence go far beyond physical injuries and deaths caused in the moment. Long-term impacts include emotional trauma, depression, and PTSD among survivors, families, and friends. Emotional trauma affects people physiologically and is linked with greater prevalence of autoimmune diseases, chronic lung and heart diseases, and use of unhealthy coping mechanisms.

From a social determinant perspective, violence extracts a toll in the form of legal bills, medical bills, and more—factors that impact where people can live and how they can pay for food, creating socioeconomic strains that perpetuate the adverse health care cycle.

Police custody violence represents a health issue that is different in kind from violence generally—carrying with it all of the baseline health consequences, plus an additional layer of emotional trauma. And the racial disparities associated with experiencing police custody violence are striking: For instance, one recent study found that black males are about 2.5 times as likely as white males to die during an encounter with police.

6. Black Americans are also more likely to suffer from the psychological effects of 'weathering'

The statistics surrounding health disparities are stark. To give just one example, black women are almost three times more likely to die of a pregnancy-related death—even after controlling for socioeconomic status. A black woman with a college education is more likely to have a negative health outcome during pregnancy compared to a white woman who never graduated from high school.

Racial disparities are driven by a wide variety of problems and have a wide variety of solutions. But it is essential that health care leaders understand that structural and interpersonal racism, bias, and prejudice take a physical toll on people's health. 

The aggregate health threat of racism-linked ongoing stress is called "weathering." Weathering, together with all the individual risks and threats of racism, together contribute to drastically lower life expectancies for black Americans. For example, in Washington D.C., a black man's life expectancy is shorter by 15 years, and a black woman's by nine years, compared to their white counterparts.

7. You should invest in collecting local and organization-specific data about racial disparities

Organization- and community-specific data collection is important, according to Sullivan, because it combats the problem of denial: Many stakeholders resist believing that structural racism is present and consequential at their own home organizations.

Data can help reveal to staff and leaders that biased practices exist not just in the communities that health care organizations serve, but also within the walls of the health care organization itself. Then, guided by this data, leaders must look inward at policies, resourcing, and behaviors among even the most well-intentioned of providers and staff.   

Anecdotally, recent Advisory Board research has found health systems are making sure that their staff-facing trainings on unconscious bias and anti-racism are extending to their own security staff. 

8. Mitigate the threat of disparate Covid-19 outcomes in your community

Now is the time for health care leaders to ensure that their outreach efforts are targeted and effective in high-risk communities, especially black communities.  

Steps include:

  • Make sure your prevention advice is practical and understandable: Check verbal and published communications to ensure it's understandable at all levels of health literacy. Define terms that may be unfamiliar to some, such as "quarantine" and "social distancing." Ensure communication and outreach are attuned to the culture of the communities receiving them.

  • Work with and through community partners. Use partners who have already built trust and relationships to provide help to communities. For example, some provider organizations have begun to offer excess masks and hand sanitizer to community partner organizations, such as food banks, to distribute.

  • Activate your community health workers and care management platform: Stratify the population, identify high-risk patients, and proactively reach out to those individuals.

  • Double down on your commitment to patient-centered care for every patient. Frontline clinicians are under tremendous strain and stress—but they still must remain focused on interpersonal best practices, such as motivational interviewing, shared decision-making, getting to know patients, and building trust. These practices are essential for providing equitable care.

9. Boosting your staff's resilience can indirectly boost health equity

Staff cannot provide the kind of high-quality, patient-centered, compassionate care that reduces health disparities if they are burned out. As such, broad-based efforts to boost staff resilience also represent a critical lever to advance health equity.   

Sullivan recommended that health leaders prioritize steps such as creating a safe and healing space for staff to grieve recent events—including the ongoing stress of living in a pandemic, but also the new layers created by recent crises and deaths. Managers also should proactively reach out to offer individualized support, whether in the form of time off, assistance with work tasks, or other measures as appropriate.

Leaders should exercise particular care in reaching out to employee resource or affinity groups for people of color or black people. Ask whether members of these groups want to help shape the organization's response to the current crisis—but don't lean on them to do all the work.  All staff in the organization, and especially members of these groups, need to see the organization taking a strong stance from the top.

10. Turn your hospital/system into an 'anchor' organization

In recent years, Advisory Board researchers have closely studied how health care organizations can achieve a wider impact. Our research suggests that a key step is to treat the hospital as "advocate" and "anchor" to help spark structural change.

Health care organizations as advocates: Use your existing government affairs arms and local/regional/national clout to advocate for polices and resources that address barriers and lift community health. For example, the American Medical Association has recently identified police violence as a top issue, tying it to the history of racism. As Sullivan explained, "That was really powerful. It showed that these issues do not have to be a third rail in health care. Your mission is to protect patient lives—it makes sense for hospitals to say 'black lives matter.'"

Health care organizations as anchors: Leverage your power as pillar of the community, major employer, and purchaser to lift the economic vitality of the community. Among these potential steps are ensuring all staff are paid a living wage, as well as hiring employees from the communities your organization serves—which requires building pathways from the community into the organization, as well as helping entry-level staff move up in the ranks.  Additional possibilities include contracting for supplies and services with local businesses owned by people or women of color, or considering social impact loans to support community organizations.

Slide deck: The vital role that health care leaders play in combating structural racism

In last week's webinar, Christopher Kerns was joined by health equity researcher Darby Sullivan to discuss the impact that racism has on health care (including disparities in the impact of Covid-19) and the vital role that health care leaders play in combating structural racism, both during the pandemic and beyond.

Get the Deck