In a frank discussion of health equity for people of color, a call to action includes addressing a long list of unmet social needs

By Melissa Patrick
Kentucky Health News

Addressing health disparities and inequities requires a commitment to address the unmet social needs that contribute to poor health, and that holds true in both African American and rural communities.

That was the underlying message in a July 12 webinar hosted by the Foundation for a Healthy Kentucky, titled “Covid-19 and Health Equity in Kentucky: Beyond this Pandemic.”

Those unmet needs are often called social determinants of health and include things like  housing, environmental exposures, transportation, food insecurity, education, healthcare and employment. They matter because researchers have found that they account for 80 percent of health outcomes.

Anita Fernander, UK professor

Dr. Anita Fernander, associate professor of behavioral science at the University of Kentucky College of Medicine, called on Kentucky and the rest of the nation to address these health disparities, which have become even more evident during the pandemic, through a social-justice approach.

“From the time covid-19 became apparent in the U.S., it became evident that communities of color were disproportionately burdened by the virus,” she said. “In almost every state where racial data is available, African Americans have higher cases of exposure, infection, hospitalizations, and deaths due to covid-19.”

In Kentucky, 14.9% of coronavirus cases and 16.7% of covid-19 deaths have been among African Americans, who make up 8.4% of the state’s population.

Fernander said African Americans are at a higher risk for exposure to the virus because they much more likely to work in service jobs and not able to work from home, and are more vulnerable to it because they have high rates of chronic disease, which stems from systemic inequalities driven by racism.

“While it may be expedient to point to genetic differences, individual behaviors, or other racialized myths as the cause of pre-existing, chronic conditions, and covid-19’s accessibility among African Americans,” she said, “it must be emphasized that these pre-existing, chronic illnesses are not accounted for by inherent biological predispositions due to race.”

Fernander spoke in great detail about how social determinants, embedded in racism, have increased health risks for African Americans.

For example, she called the lack of financial stability among Blacks a “fundamental risk factor.” She said they are more likely to be poor, have twice the poverty rate, and have significantly lower household incomes than white Americans, and much less home ownership – a disparity that she said hasn’t changed since 1968.

That stems in part from banks’ refusal to lend to people of color for property in certain neighborhoods. This “redlining” practice has been outlawed, but Fernander said it has lasting impacts in Black neighborhoods: high rates of air pollution, poor water quality, a lack of green space, “food deserts,” substandard housing and limited access to hospitals and clinics.

“Place matters when it comes to health,” she said. “Your ZIP code matters more than your genetic code.”

Fernander spoke to a long list of social determinants that she said need attention: The top 10 counties with the highest food-insecurity rates are all at least 60% African American; Blacks make up 40% of the homeless population; are victims of racialized policing; their incarceration rate is more than six times that of their white counterparts; that they are grossly under-represented in civic engagement; and are more likely to lack health insurance or be under-insured.

“Because an individual’s health is significantly determined by social factors and the existence of health disparities are due to structural and systemic factors that impact the social determinants of health,” Fernander concluded, “it follows that a social-justice approach for addressing health disparities be undertaken not only in pandemic crises but in times of normality when crises are not as apparent.”

Call for action

Sadiqa N. Reynolds

Sadiqa N. Reynolds, president and CEO of the Louisville Urban League, emphasized many of the same points.

“There is no sense that Black people have access to the same justice as white Americans, to the same anything,” she said. “Not when it comes to the criminal-justice system or police, not when it comes to workforce, not when it comes to education. There are so many deficiencies. And we know, because you all are smart enough to know, that this is intentional, Right? There is intentional structural racism that we are fighting against.”

Reynolds called for significant investments in affordable housing for African Americans as well as investments in small businesses and education, and said if those investments aren’t large enough to change economic outcomes, then we are only putting a Band-Aid on the problem.

“We have to change economic outcomes if you really want to change health, health equity,” she said.

Reynolds spoke with great passion about the ongoing protest against police violence in Louisville and across the nation: “We want peace, but not without justice. We want good people to stop being quiet when our lives are slowly picked apart. We want good people to invest in ways that change outcomes for people who have no control over policy. We want people to be outraged when we die, whether it is from lack of insulin because we cannot afford it or police brutality. If in fact, my life matters, show me how.”

Rural Kentucky and the pandemic

Fran Feltner, rural health center director

Fran Feltner, director of the Center of Excellence in Rural Health, said her team of community health workers at Kentucky Homeplace work everyday to address many of the same social determinants of health in Appalachian Kentucky.

The CHW program revamped how it delivered services very quickly after the coronavirus hit, shifting to providing services virtually or on the phone, instead of face-to-face, Feltner said: “This was very important because the population that we serve is the most vulnerable population; most all of them are at 100% of poverty.”

Feltner said the challenges caused by social determinants of health multiplied during the pandemic, including social and geographical isolation.

She said about 67% of the people served by community health workers have a lack of social supports, and their only contact with the outside world is their CHW, who works to make sure that their basic needs are being met and that they are able to manage their chronic illnesses.

“That’s why it was so important to keep Kentucky Homeplace CHWs working during this pandemic,” she said.

Key questions for policymakers 

Heather Howard of State Health and Value Strategies at Princeton University said states should ask five key questions about health equity in the pandemic:

  • Have we identified a person or team of people to apply an equity lens to all of our covid-19 response and recovery efforts?
  • Have we identified at-risk populations and targeted resources specifically to those populations, employing national cultural and linguistically appropriate standards?
  • Have we issued any guidelines that foster health inequity?
  • Are we collecting, analyzing, reporting, and using demographic data for covid-19 testing, hospitalization, and deaths? Is the data from covid-19 being reported so that our responses are equitable?
  • Have we collaborated with community organizations and members of heavily impacted neighborhoods to address gaps in outreach and build trust?
Howard said Kentucky is doing well with its data and policy response:  “You’ve got some great initiatives going on, the governor just this week announced an expansion to health insurance, but you need data to ground good policy, to drive the best way to address inequities, and especially its resource allocation.”

Foundation: Racism is a barrier to equityIn conjunction with the webinar, the foundation issued a statement about racism’s role in health inequities:”Racism kills every day. The horrific deaths of African Americans in the past weeks are brutal reminders that individual, institutional and structural racism have deadly consequences.  Sometimes the consequences are immediate. They garner national headlines that spur outrage and protest. The vast majority of the time, they take lives without a massive public display of grief and demands for change.”The covid-19 pandemic has exposed and exacerbated the persistent and pervasive racial and ethnic health inequities that are a direct result of . . . a racism that is inherent in systems and policies governing housing, jobs, education and health care in our country. A racism that leads to higher rates of coronavirus exposure, greater risk of complications, and less access to medical treatment for African Americans.”If we are not its victims, we cannot fully understand the costs of racism. But as humans, we can listen, empathize, and learn. And we can demand change, both in ourselves, and in the structures that perpetuate inequities as a result of racism.”The Foundation for a Healthy Kentucky is focused, at its very core, on addressing the unmet health needs of Kentuckians by developing and influencing policy, improving access to care, reducing health risks and disparities, and promoting health equity. Our vision is a commonwealth where every individual and community reach their highest levels of health.”Racism is a systemic barrier hindering that vision. We condemn it. We grieve with those who are suffering its consequences this week, and every week. And we are committed to doing our part to raise the voices of those who suffer and bringing about systemic change. . . . Meanwhile, we recognize that now is a time for listening, and not for silence. We stand with the African American community in Kentucky and in America, and against racism in all its forms.”
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