Feature ArticleThe Health Care Institution, Population Health and Black Lives
Introduction
While some may assert we live in a post-racial era, a body of scholarship corroborates the presence of structural racism in contemporary settings.1, 2, 3, 4, 5 Most recently, a series of events have elevated social consciousness about the Black experience in America.6 Consequently, the Black Lives Matter movement gained momentum in 2012, serving as a “call to action and a response to the virulent anti-Black racism that permeates our society.7” The mission specifically focuses on addressing “ongoing and widespread devaluation of Black Lives and the social, political, and economical structures that result in unequal opportunity.7” Such forms of injustice have a profound effect on communities of color and are manifested through inequities in common correlates of health, including access to quality education, healthy foods, livable wages, and affordable housing.
Moreover, a substantial body of evidence highlights the relationship between race, racism and health status.8, 9, 10, 11, 12 Blacks are disproportionately burdened by poorer access and lower quality of care even when controlling for factors, such as income, education, and insurance.8, 13 They also represent higher rates of morbidity and premature mortality when compared with white counterparts. Some of the starkest differences can be found in hypertension, diabetes, and asthma rates, resulting in higher frequencies of treatment for comorbidities and ambulatory care sensitive conditions.14, 15, 16, 17, 18, 19 Such racial disparities have a significant financial impact and are estimated to cost $35 billion in excess health care expenditures and $10 billion in illness-related lost productivity.20
In response to these disparities, many health care institutions have demographically stratified and analyzed health outcome data and incorporated best practices to create interventions to reduce or eliminate disparities in care. However, due to broader structural contexts, significant disparities persist. We assert that these trends will remain intractable until structural racism and its effects (bias, discrimination) are recognized as root causes of poor health. This approach is especially relevant as health reform is incentivizing health care leaders to find new and more creative ways to promote wellness, reduce readmissions, and manage the health of populations. By applying a racial equity lens in how they are governed and operated, hospitals, as anchor institutions, can advance their population health goals.21
Using health reform as a springboard, we articulate why this approach is important and close with a conceptual framework to stimulate thought and organizational practices that (1) promote racial equity within health care settings; and (2) contribute to the advancement of historically marginalized communities of color.
Section snippets
Health Equity and Black Lives
In light of the magnitude and long-term psychological impact of racism, coupled with a history of implicit and explicit injustices imposed on those of African descent, two definitions in the literature inform our interpretation of health equity within the context of Black Lives. In 2003, Braveman and Gruskin defined health equity as a goal of eliminating systemic disparities in health or in the major social determinants of health (i.e., education, housing, employment) between social groups who
Institutionalized Racism and Its Effects
In order to be effective in improving health through a racial equity lens, it is important to recognize how the health care institution is a subset of a larger ecosystem with vestiges of institutionalized racism, stemming as far back as the 1600s.9 The legacy continues to influence how low income communities of color are structured and resourced.23, 24 Institutionalized racism is defined as “the structures, policies, practices, and norms resulting in differential access to the goods, services,
Population Health
The gravity of these dynamics must be recognized within the context of population health – a term that has progressively increased in the literature since 2010.45 While the interpretation and its utility tend to vary depending on discipline or profession, health care institutions are likely to perceive population health as clinically managing the patients under the auspices of their care. However, health outcomes for these patients are heavily influenced by structural conditions and the quality
Conceptual Framework
Hospitals are components of a larger ecosystem; they cannot take sole responsibility for addressing complex and intersectional inequities that perpetuate poor health in communities of color. However, as health care providers, they can be instrumental in eliminating racial disparities within clinical settings, and as anchor institutions, they can be socially impactful – using their business models to create opportunity and stimulate investments in historically marginalized communities. To incite
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