From the Editor in Chief
Feb 2020

Motivating Health Equity

Audiey C. Kao, MD, PhD
AMA J Ethics. 2020;22(2):E69-72. doi: 10.100/amajethics.2020.69.

 

It was one of the hottest and muggiest days of the summer, and I was lunching al fresco with friends at a neighborhood pub. As we ate, drank, and chatted, my gaze happened upon a person sitting on the sidewalk down the street. After parting ways, I went to pick up a prescription and realized this person was actually motionless, his head slumped on his chest. A sign was propped on his left side describing his life circumstance and asking for money. As I walked into the store, my mind was whirling: Was it heat stroke? Should I do something? Is he dead!?! He’s fine. Where’s my wallet?

Waiting in the pharmacy line gave me a moment to ponder what to do next. I decided to check on this man and bring him something cold to drink. Hesitating briefly, I approached him, bent down, and jostled his right shoulder. This roused him and I introduced myself. He said, “I’m okay.” I gave him a couple of fruit smoothies. He shook my hand. I started home.

Those of us with means and standing can expect to live longer, fuller lives than ever before. Those of us with less or little struggle to simply get through a day. In the city where I live, a recent study found that 2 neighborhoods, one predominantly black and the other mainly white, had a life expectancy gap of 30 years.1 Inequity in health status of this magnitude is not accidental but a consequence of transgenerationally entrenched power structures that produce and reproduce inequity over time.2 This is a justice problem and cannot be fixed without tackling social, political, and economic root causes that advantage some of us and disadvantage some of us. With the reemergence of white nationalism and xenophobic bigotry, structural racism and its harms to individuals’ and communities’ health demand urgent attention, especially from those called upon to care for the sick and injured.3

Physicians are expected to embody medicine’s ethical oaths and codes, to apply clinical knowledge and skills without prejudice. Yet evidence of racial and ethnic disparities in health care persistently reveals unequal treatment, even after accounting for differences in access to care and patient preferences.4,5 This evidence cannot be ignored or rationalized away, and the US medical profession must not ignore or discount its role in this nation’s history of segregation and racism.6 The impact of this legacy—still evident in the number of underrepresented minority physicians7 and false beliefs about biological differences among racial groups8—must be understood in terms of how our past has situated our present. We, as members of the medical profession, are obliged to confront this past.9 Only then can the medical profession aspire to make good on a commitment to mitigate, and to eliminate over time, inequities in health status and outcomes.

The AMA Journal of Ethics is committed to catalyzing greater appreciation for and understanding of health equity and to motivating “assurance of the conditions for optimal health for all people.”2 This editorial commitment is not a new one, as the journal has published a variety of content on health equity. That said, motivating health equity requires deep examination of critical issues that are particularly complex and potentially divisive. From a micro or individual perspective, how should personal accountability factor into health equity? How much should we expect individuals to take responsibility for their own health status? From a macro or policy perspective, how far are we willing to stray from what economists call Pareto efficiency? Should society accept resource allocation decisions that make some people better off while making some people somewhat worse off? The journal invites submissions examining these and other thought-provoking ethical questions.

Furthermore, each issue of the journal will explore some dimension of health equity, regardless of whether the theme is humor in health care (forthcoming in July 2020) or Native American health (forthcoming in October 2020). An entire theme issue dedicated to racial justice and health equity is slated for February 2021. Foci of particular interest include innovations in bias training, organizational responses to unequal treatment, policy solutions to root causes of health status disparities, legal approaches to historical injustices and trauma, and social activism of health care professionals.

As I crossed the intersection, a driver waiting for the light to turn green flashed me a “thumbs up.” Emojied acknowledgment aside, I thought of the man on the street corner, his vulnerability, his future, and how we can do more.

References

  1. Schencker L. Chicago’s lifespan gap: Streeterville residents live to 90. Englewood residents die at 60. Study finds it’s the largest divide in the US. Chicago Tribune. June 6, 2019. https://www.chicagotribune.com/business/ct-biz-chicago-has-largest-life-expectancy-gap-between-neighborhoods-20190605-story.html. Accessed November 21, 2019.

  2. Jones CP. Systems of power, axes of inequity: parallels, intersections, braiding the strands. Med Care. 2014;52(10)(Suppl3):S71-S75.
  3. Trent M, Dooley DG, Dougé J. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765.

  4. Smedley BD, Stith AY, Nelson AR, eds; Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.

  5. Fiscella K, Sanders MR. Racial and ethnic disparities in the quality of health care. Annu Rev Public Health. 2016;37:375-394.

  6. Baker RB, Washington HA, Olakanmi O, et al. African American physicians and organized medicine, 1846-1968: origins of a racial divide. JAMA. 2008;300(3):306-313.
  7. National Academies of Sciences, Engineering, and Medicine. An American Crisis: The Growing Absence of Black Men in Medicine and Science: Proceedings of a Joint Workshop. Washington, DC: National Academies Press; 2018.

  8. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301.
  9. Davis RM. Achieving racial harmony for the benefit of patients and communities: contrition, reconciliation, and collaboration. JAMA. 2008;300(3):323-325.

Citation

AMA J Ethics. 2020;22(2):E69-72.

DOI

10.100/amajethics.2020.69.

Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.