"Of all the forms of inequality, injustice in health is the most shocking and inhumane." These words were spoken by Reverend Dr. Martin Luther King, Jr. over forty years ago. While the health status of all Americans has improved significantly since that time, injustice in health continues to exist in the United States and in our Commonwealth.
Recent research estimates that nationally there are roughly 83,000 excess deaths among African Americans and 195,000 excess deaths among lesser educated adults compared to college educated adults every year. In fact, the United States ranked 14th in the world for life expectancy in 1980. In 2007, we ranked 29th. According to the Robert Wood Johnson Foundation, health inequity costs the United States more than $1 trillion per year. The forthcoming 2008 Virginia Health Equity Report highlights health inequities that exist in Virginia by socioeconomic status (SES), race and ethnicity, gender, neighborhood and geography. Not only are the most disadvantaged Virginians at increased risk for a multitude of adverse health outcomes, but even Virginians in the middle experience poorer average health outcomes than those with the greatest level of social and economic advantage. Eliminating health inequities should be a priority for all Virginians.
I’m often asked by my colleagues and other health professionals, "what specifically can I do to support efforts to eliminate health inequities?" My immediate response is, "The first step is to recognize that health inequities are systematic, avoidable and unjust because they result from social and economic policies, practices, and conditions that disadvantage certain populations and create barriers to opportunities to live productive and healthy lives." This recognition requires a different framework, one that is supported by research demonstrating that individual and neighborhood-level socioeconomic status are strongly associated with most of the major causes of death, even after controlling for access to health care, health behaviors, and other risk factors. This framework recognizes the importance of promoting social justice by addressing the unequal distribution of social determinants of health—such as income, education, and wealth; discrimination by class, race, and/or gender; quality and affordable housing; healthy neighborhood environments; social support and social capital; transportation; working conditions and others.
The new framework by no means diminishes the good work that leads to improved access to quality health care, behavior change, etc. Rather, it demands that our focus in these areas be informed by a commitment to advance health equity and social justice. Within the healthcare setting, that means things such as:
Within efforts to promote healthy behaviors, a commitment to health equity and social justice includes:
Ultimately, eliminating health inequities requires addressing the social determinants of health and their unequal distribution. While this focus is new to many of us in the health and medical communities, the reality is that expert panels from around the world have been studying this issue for many years. Several commissions have been formed or have released reports with recommendations on the policies (health, social, and economic) that are necessary to achieve health equity. In addition to partnerships across sectors, implementing healthy policies requires public policy makers to appreciate the health effects of social policies that may not appear to directly affect health. Some examples include:
The work my office is engaged in provides some specific examples of how organizations can promote health equity and social justice. As our framework for action demonstrates, our mission and vision guide our programmatic work. At the core of this work are data analysis and research to define the distribution of health, disease, and social determinants of health; and to identify local high priority target areas. Our programmatic areas focus on health care, policies that promote health, and empowerment of disadvantaged communities. These priorities advance health equity by promoting access to quality health care, healthy public policy, and healthy and engaged communities. We hope that you, too, will join us in our efforts to advance health equity for all Virginians.
Michael O. Royster, MD, MPH
Director of the Office of Minority Health and Public Health Policy