HEALTH CARE EQUITY & JUSTICE PILLAR

A Look at The Toledo Black Agenda

A wide range of leaders in Toledo’s Black community have joined forces to put together a report on the challenges facing that community in six critical areas.

The report, The Toledo Black Agenda, a months-long project in the making, examines historic obstacles and current challenges in the areas of criminal justice, economic development, education, health, housing, workforce development.

The community leaders and experts were assembled by Lisa McDuffie, CEO of YWCA of Northwest Ohio and Robin Reese, CEO of Lucas County Children Services.

Now Toledo’s Black Agenda will be made available to local government agencies, along with a host of private and public companies and entities in order to gather community-wide support for the demands and suggestions proposed in the report.

We are printing excerpts from the report over the next few weeks. The following is an excerpt from the fourth pillar – the Health Care Equity & Justice Pillar. We will print the recommendations of the Health Care Task Force next week.

The entire report, with citations, can be read online at thetruthtoledo.com

PART IV:  HEALTH CARE EQUITY & JUSTICE PILLAR

INTRODUCTION AND PURPOSE

The issue of equity in healthcare is a complicated one.  To improve health for everyone, hard, unflinching questions must be asked, and reasonable, innovative and well-formed solutions designed to directly address the needs of those disenfranchised in our communities must be provided. There can be no fear of confronting history and its fostering of the intentional development of public policies that “ghettoized” neighborhoods making them unhealthy places for families to live. We must ask why housing stock is allowed to remain infested with lead, well known to impair the cognitive ability of our children.  We must challenge our elected officials to answer the question why, in the most progressive and technologically advanced time in our history, in the richest country in the world, issues of food insecurity, educational process that fail many children in our urban centers and environmental issues that deprive our communities of life sustaining basics like water, still exist?  Employment and associated advancements are still unevenly available and the inability or unwillingness to provide equal access to health care, especially specialty care, remains of great concern. Tough questions with no easy solutions, but all necessary inquiries in the movement toward healthcare equity.

What Is Health Equity?

A basic principle of public health is that all people have a right to health care^[1].  When access to care is denied, significant negative differences in the health status between groups occur.  These differences most often affect those who are marginalized because of socioeconomic status, race/ethnicity, sexual orientation, gender, disability status, geographic location, or some combination thereof. People in these groups not only experience worse health but also tend to have less access to those resources which typically form the foundation of healthy communities. Suitable housing, sound education nutritional food and safe neighborhoods are all examples of what are now called the Social Determinants of Health (SDOH) and are considered essential resources in the pursuit of Health Equity.^[2]

The actual definition of Health Equity is complicated by the influences of those elements related to SDOH and its similarity to its counterparts, Health Disparities and Inclusion Health. The World Health Organization defines health equity as the “absence of avoidable, unfair or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, geographically or by other means of stratification” in the pursuit of optimal health status.^[3]  It is, as defined within the Veterans Health Administration’s Health Equity Plan, “the understanding of how people’s social characteristics and environments affect health…” ^[4]  These are the definitions of health equity to be used within this document. Health inequities are not naturally made.  They arise from racial and class inequities; from decisions that this society has made.  The single strongest predictor of our health is our position on the class pyramid.

The issue of Health Equity is both massive in scope and complex when considering a pathway toward its attainment.   And while there are a significant number of health issues that should be addressed by this community, this document will identify those health issues in our community that require immediate consideration.  One thing is without question; the data and research evidence are clear that racism is a systemic and ongoing public health crisis with serious consequences for the health of Black Ohioans. It is also clear that racism has a profound and pervasive impact across all the factors that shape our health. This includes our healthcare delivery systems, education, housing, food, economic, environmental, criminal justice and political systems, among others.^[5]

 Health disparities on the other hand, are the health-related outcomes present in marginalized communities, which are directly attributable to the systematic and unjust distribution of those critical resources mentioned above.  Equally important is the somewhat derivative definition of Inclusion Health.  This term  is used to define a number of groups of people who are not usually well provided for by healthcare systems, have poorer, access to healthcare , experiences and health outcomes than even the most vulnerable of our population.^[6] This definition covers people who are homeless, vulnerable migrants (refugees, those undocumented, asylum seekers) and sex workers to name a few. The conceptual differences between these terms are subtle but significant. It is important however, that they and their differences be understood as each is important in this discussion.

The Cumulative Impact of Healthcare Inequity

Racism and the inequities it creates are well documented as drivers of health disparities and overall poor health in the Black community. While these are avoidable differences in health outcomes among groups, the ongoing trauma of systemic or institutional racism, results in an unequal allocation of social resources that shape health status.  Resulting imbalances can be seen in conditions that shape and define Social Determinants of Health. ^[7]  But beyond these things, evidence suggests that the stress of the experience of racism may have its own physical impact. “It’s about access and unequal treatment, but it’s also about much more than that’ states April Thames, PhD, Associate Professor of Psychology and Director of the Social Neuroscience in Health Psychology lab at the University of Southern California.

 The fact that individuals live with these stressors their entire lives produces adverse health consequences. Discrimination has a directly toxic impact on health in general and neurologic health in particular. Several studies have shown clear biological links for poor health outcomes associated with racism, even after controlling for other factors that might serve as a proxy, such as access to care. In fact, the persistent stress of these environmental influencers causes changes to the neurological, endocrine and immune systems. These changes contribute to a great number of health maladies including high rates of infant mortality and co-morbidities such as hypertension and heart disease. Comorbidities render Black people more vulnerable to illnesses like COVID-19, shortens lifespans and increases medical complications and death from otherwise survivable diseases.

There are also real differences in how people are treated when they obtain care. The examples are many and range from providing significant misinformation (telling a patient with suspected Multiple Sclerosis that “Black people don’t get MS”) to disparities in the way illnesses are managed. For example, Black patients experiencing a stroke are one quarter less likely to be given thrombolysis, the treatment which is known to be most effective, than White patients. In her book CASTE, Isabelle Wilkerson discusses that  empirical studies show physicians often disregard the reports of pain from Black patients, wrongly believing that Blacks in particular have higher pain thresholds.  This, according to Wilkerson, has led physicians to undertreat or deny pain medication to Black patients-even those with metastatic cancer-while readily prescribing medication to White patients reporting equivalent levels of pain.  The disparity is so severe that Blacks as a group receive pain medication at levels beneath the threshold established by the World Health Organization.

California Surgeon General Dr. Nadine Burke Harris is a pediatrician who has studied the profound health effects of childhood trauma and stress.  In pointing out the higher COVID-19 rates among Black and Brown people, she identified their long term environmental and racially tinged experiences to be “severely flawed and systematically different than others, resulting in negative health outcomes. We (this country) have created these differences— and they are literally leading Black and Brown people to die in far greater numbers, than others” she said.

Ohio by The Numbers

When it comes to developing a health system rooted in the principles of health equity and justice, the numbers below will show that Ohio and Lucas county face significant challenges.

• Ohio consistently ranks among the bottom half of states on measures of health and wellbeing. For example, Ohio ranks 38 out of 50 states on America’s Health Rankings 2019 report.
• In the Health Policy Institute of Ohio’s 2019 Health Value Dashboard, Ohio ranks 46 out of 50 states and D.C. on health value, a composite measure of population health and healthcare spending,  This means that Ohioans are less healthy and spend more on health care than people in most other states.
• Ohio is in the bottom quartile (42 out of 50 states) for Black child wellbeing based on the Annie E. Casey Foundation 2017 Race for Results Report, indicating that Black children in Ohio do not have adequate supports to achieve optimal health.
• Ohioans of color face large gaps in outcomes across socio-economic factors, community conditions and health care. This, in turn, drives poorer health outcomes among Ohioans of color, such as higher rates of infant mortality and premature death.
• Women of color and low-income mothers,  are several times more likely to suffer from postpartum mental illness but less likely to receive treatment than other mothers, according to recent studies.
• According to the study, “Suicide attempts rising among Black teens.” Reuters, Oct 16, 2019, while the overall proportion of teens reporting suicidal thoughts or plans declined for all racial and ethnic groups during the study period, the proportion of Black teens attempting suicide surged by 73%.
• A Centers for Disease Control and Prevention report found that Black women are about three times more likely to die from causes related to pregnancy, compared to White women in the United States. (Source: “Huge Racial Disparities Found in Deaths Linked to Pregnancy,” New York Times, May 7, 2019)
• In Cleveland, Ohio Black babies are dying at a rate of 7 times that of White babies. Generally, in Ohio, Black infants die at a rate of 2-3 times that of White infants
• Black children are almost three and a half times more likely to die within 30 days after surgery than White children, according to a new study published in the journal Pediatrics
• Twenty percent of Ohio children live in poverty (Spotlight on Poverty and Opportunity 2019)
• Blacks have the highest mortality rate for all cancers combined compared with any other racial and ethnic group.
• The likelihood of having two or more significant conditions is 60% by the age of 75-79 years, and more than 75% by 85-89 years causing most Seniors to suffer complications from comorbidities.
• Food insecurity in Ohio has nearly doubled from 13.9% to 23%
• In Ohio, more than one-in-six older adults (17.6 percent) face the threat of hunger. Ohio is among the 10 worst states in the nation for food insecurity among older adults, with over 457,000 Ohioans over age 60 who are either “marginally food insecure” or “food insecure,” according to a recent report by Community Solutions, “Fighting Food Insecurity Among Older Adults” (2017)

Suicide attempts for Black teens rose 73% in 2019 while they fell for every other group.  Lucas County by the Numbers

• 19.3% of Lucas County residents live in poverty, higher than the national average of 13%.
• Those poorest are women 18-34 years of age
•  38.2% of Toledo children live in poverty, compared to 28.1% in Lucas county (Toledo and Lucas County Poverty Study 2019).
• In Lucas County, white babies died at a rate of 4.7 per 1,000 live births, while the rate for Black babies was 13.7.
• In Lucas County, Ohio and the United States in 2012-2016, Blacks had higher cancer mortality rates than Whites.
• In Lucas County, one in nine (11%) Lucas County Black adults were diagnosed with cancer at some point in their lives, increasing to 25% of those over the age of 65 based on the 2017 Health Assessment.
• In Lucas County, Blacks have a higher rate of co-morbidities than Whites
• 36% of those over 65 in Lucas County rated their health as fair or poor
• Four percent (4%) of Black adults reported they had heart disease, increasing to 13% of those with incomes less than $25,000 and 14% of those over the age of 65 according to Healthy Lucas County’s 2018 Community Health Assessment.
• According to the same report, 22% of Lucas County African American adults had been diagnosed with diabetes, increasing to 45% of those over the age of 65.
•  By 2030, older adults will make up 25% of the population in Lucas County.
• 28% of Lucas County residents and 1 in 4 children experience food insecurity

Health Statistics for Black American Men

Black men in the United States suffer worse health than any other racial group in America.  As a group, Black men have the lowest life expectancy and the highest death rate from specific causes when compared to both men and women of other racial and ethnic groups.

Statistically speaking, Black men live 7 years less than men of other racial groups. They have a higher death than Black women for all leading causes of death. Black men suffer more from preventable oral diseases that are treatable, have a higher incidence of diabetes and prostate cancer.  In Lucas County, Black men have a 38% obesity rate and 44% are considered overweight. Suicide is the third leading cause of death in 15-24-year-old Black men. In 2017, homicide was the number one cause of death for young Black men between the ages of 15 and 44.

Ed. Note: The Task Force’s recommendations will be published next week.