The High Cost of Inequity in Health Care

February 18, 2021

Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.

– Dr. Martin Luther King, Jr.


As we assess the last 12 months of a global struggle with COVID-19, and with glaring inequities in health care in the US, we can see both the darkness and the light.

There have been incalculable losses of 2.4 million deaths globally attributed to the virus, sharp increases in mortality rates associated with cardiovascular disease, and a steep drop in preventive care, of which we will see the effects for years to come.

At the same time, optimism and hope have come from the remarkable dedication of healthcare and other essential front-line workers, from the global scientific community as vaccines have become a reality in record time, and from local heroes lifting communities in need.

But a more thorough evaluation means we must recognize the devastating realities of social inequity within our healthcare system. Remarkable work has been published by thoughtful clinicians in The American Journal of Preventive Medicine, JAMA Network Open, and others. The global pandemic has laid bare long-known inequities intimately intertwined with institutional or structural racism forcing marginalized communities to carry an undue burden.

The authors of the JAMA Network Open article point out that COVID-19 substantially increased the risks faced by America’s most at-risk communities. For example, African American individuals in Michigan experienced 31% of the state’s early COVID-19 cases while representing only 14% of the state’s population. Additionally, the authors draw attention in New York City to the disproportionate number of hospitalizations and deaths related to COVID-19 in the Bronx, the borough with the largest percentage of minority groups and households in poverty.

Sadly, this is simply another proofpoint that vulnerable communities have less access to healthcare. Pre-pandemic data published in April 2020 showed that “patients at physician practices serving the most disadvantaged populations were more likely to be admitted to the hospital for unstable angina.” These patients face burdens to fill basic prescriptions and preventive visits which are often beyond reach meaning that previously treatable diseases are seen at more advanced stages.

So what now? What can be done? We already know that COVID vaccinations are not reaching communities equitably, even with many making a concerted effort to ensure those at risk are prioritized. So does that mean that even our best efforts will come up short? Maybe it does, but we must continue to try and to seek new solutions. There is a crucial difference between an effort to prioritize the vulnerable and an effort to race “back to normal” where we gloss over the pain socially vulnerable communities bear.

Regardless of your politics, we can agree that there is work to be done, and this month has had multiple groups announcing new efforts. The White House announced a “COVID-19 Health Equity Task Force” working to consider how to address, or at least not exacerbate, inequitable healthcare. States are proposing to create a state-level Office of Health Equity and governors are discussing how they will work toward equity now and beyond. Even peer-reviewed journals are acknowledging their opportunity to address racism and bias in data gathering, review, and presentation.

All of these efforts are welcomed, but each of us must still consider what we will do to support change where we are right now. Although we ourselves may not be able to increase funding for the local county hospitals serving the most vulnerable patients, we can commit ourselves to ask about the actions of our hospitals and community leaders to support such efforts.

On top of it all, remember that health inequity and disparities of social determinants of health are downstream results of institutional and structural racism driving socioeconomic disadvantage. With this recognition, we can all commit to learn about these realities, and by doing so, begin to change them.

— A perspective from HeartFlow Chief Medical Officer, Campbell Rogers, MD
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