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Authored by Elana Brochin
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Advancing the Racial Equity Lens Within Healthcare

October 29th, 2019 by Elana Brochin

Image courtesy of the Boston Public Health Commission’s Racial Justice and Health Equity Initiative.

Massachusetts recently opened the door for community organizations to engage with health care institutions in moving the needle on what are commonly referred to as “Social Determinants of Health.” Social Determinants of Health (SDoH) are the conditions in which we live, work, and age and which impact our health outcomes. The Department of Public Health’s (DPH) recently updated Determination of Need (DoN) regulations and the Attorney General’s Office’s (AGO) updated Community Benefits Guidelines both emphasize that investment in SDoH is necessary to move the needle on health care outcomes. In particular, the DoN regulations identified the following Social Determinants of Health (SDoH) as priority areas: built environment, social environment, education, employment, violence, and housing. These same priorities were adopted in the AGO’s Community Benefits Guidelines.

In addition to emphasizing SDoH, the DoN subregulations describe an opportunity for “the Commonwealth to address health inequities based on race, class, and other socioeconomic factors, which are a result of historical policies and practices.” The AGO Guidelines further assert that “Racism has an independent influence on all social determinants of health, and racism in and of itself has a harmful impact on health.” Together, these guidelines open the door for community advocates to move health care policy conversations towards explicitly addressing racism as a social determinant of health.

The challenge to organizations like MACDC is how to effectively push health care institutions to adopt racial justice as the primary lens with which to address health inequities. MACDC has been engaged in moving health care institutional focus toward racial equity through active engagement with:

The Boston Community Health Needs Assessment Collaborative – Several Boston area hospitals recently collaborated on a joint Boston Community Health Needs Assessment (CHNA) for the first time. MACDC recognizes this collaboration as an opportunity to help direct the more than $180 million these hospitals spend annually on Community Benefits Programs. In light of our recognition of the importance of this collaboration, MACDC engaged in the CHNA process through assigning two of our members to the CHNA Steering Committee, attending community forums to prioritize goals and craft strategic approaches to achieving these goals, submitting a detailed letter to the Boston Collaborative, and submitting a detailed strategy document to the Collaborative. Through these channels, MACDC expressed support for naming the achievement of racial and ethnic health equity as a core focus/aspirational goal in which specific health goals would be encapsulated. We were pleased to the see that the Boston CHNA Collaborative ultimately adopted a lens of racial equity in their completed Community Health Needs Assessment.

The Alliance for Community Health Integration’s Housing and Health Policy Work Group – Through our membership in the Alliance for Community Health Integration (ACHI), MACDC has been part of an effort to engage health care institutions around high-level housing policy issues. This effort has resulted in a statement of principles for which ACHI is in the process of gathering signatures and two webinars that provide a high-level overview of housing policy for health care providers and executives. Because African Americans and other communities of color are disproportionately affected by housing challenges and disproportionately bear the burden of poor health outcomes, our work is inherently rooted in racial equity. Furthermore, our ongoing challenge is how to use this platform to further push health care institutions to explicitly address structural racism in the way that they talk about and address health inequity in their communities.

Our engagement in the ACHI Health and Housing Policy Work Group and with the Boston CHNA Collaborative are important areas in which to challenge health care institutions to adopt a racial equity lens. As health care institutions continue to define their missions, agendas, and programs under the new state guidance, it is our job, as anti-racist community advocates, to continue to challenge health care institutions to tackle their community health work from a racial equity perspective.

 

Defining Health Equity: “I know it when I see it”

August 27th, 2019 by Elana Brochin

In the five months since I started at MACDC as the Program Director for Health Equity, I have struggled to define the key term imbedded in my title: “health equity.” Rather than using a single definition for this important term, I have found that the term is better described through examples, in other words, I know it when I see it.  

“I know it when I see it” is a concept popularized by the former Supreme Court Justice Potter Stewart in 1964 when he described the concept as the threshold test for obscenity regarding protected speech. In the same way that “obscenity” has variable definitions yet is recognized when it exists, health equity is better defined by examples than by a static definition.  

Health equity is the opening of a grocery store to increase access to healthy, affordable food to low- and moderate-income residents who have disproportionate rates of diabetes, heart disease, and high blood pressure. Health equity is advocating for increased state funding for no-interest lead abatement loans for low- and moderate-income homeowners and landlords. Health equity is providing transportation services for isolated seniors to access health care services and health-promoting activities. But despite having a clear sense of examples of initiatives that fall into the health equity bucket, it is often advantageous to have a succinct definition for health equity for shorter conversations. 

MACDC has not formally adopted a definition for health equity, and so, in order to better articulate what I do, I recently did some research into how other organizations define the term. The following are several definitions of health equity, followed by my initial reactions: 

The World Health Organization (WHO) 

Definition: Equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically, or by other means of stratification. "Health equity” or “equity in health” implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential. 

My reaction: I like that this definition begins by defining “equity” and then gets more specific in defining what we mean by health equity. The WHO leaves me wanting more detail about the systems and causes of inequity. 

Center for Disease Control (the other CDC)  

Definition: Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment. 

My reaction: I really like that this definition enumerates how health inequity manifests. This definition made me appreciate an aspect of the WHO definition, which the CDC definition lacks: the WHO names social, economic, demographic, and geographic as ways in which people might be subject to varying health outcomes. 

Robert Wood Johnson Foundation (RWJF) 

Definition: Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. 

My reaction: I really like that RWJF names the social determinants of health that cause health inequity. I have mixed feelings about the first sentence in their definition, which on one hand, describes the desired outcome (“everyone….to be as healthy as possible”), on the other, doesn’t define what we mean by good health.  

American Public Health Association  

Definition: Everyone has the opportunity to attain their highest level of health. 

My reaction: Wow, this is an even more simplified version than the first sentence of the RWJF definition! I like that the definition is straight-forward, but also am concerned that its simplicity renders makes it less useful than the other definitions. 

I was curious to analyze these definitions together to better understand what they have in common. I started by creating a word bubble: 

To better understand the word bubble, I noted the words that appeared the biggest – meaning that they appeared most frequently. I came up with the following words: everyone, attain, fair, potential, opportunity. These five words seem to be moving toward a consensus definition – in fact, they almost make a sentence. But something is notably missing – there are no words that are specific to health! In fact, the words in this word bubble that are most directly tied to health, consistently appear the smallest. These words include disease, death, care, treatment, disability and almost entirely stem from the CDC definition. 

 

My analysis of the word bubble indicates that the definitions cited are in better agreement about how to define “equity” than they are about how to define “health.” I have a few theories as to why: 

 

One theory is that the definitions assume that we know what health is, but assume we need help defining equity.  

 

Conversely another theory is that health is just too difficult to define in the context of a succinct definition.  

 

The most compelling explanation for the absence of health-specific terms in these definitions is that differences in health status or health opportunities stem from the same inequities from which all unequal outcomes stem. Therefore, these definitions are more concerned with the cause (inequity) than the effect (health).  

 

I hope that instead of creating more confusion (which would be understandable), my analysis provides a bit of understanding of what health equity is. I think it helped me! Going forward, when someone asks me what I do, I’m going to go with something along the lines of: 

 

Health equity involves creating and supporting systems, environments, and policies that allow all individuals the potential to lead healthy lives. Health equity further involves dismantling systems, environments, and policies that have historically contributed to health disparities. When time allows, my explanation will undoubtedly be followed by a laundry list of examples of ways in which CDCs, and others, are actively working to promote health equity. I maintain that ultimately real-world examples will better explain health equity than any definition can. 

 

Do you or your organization have a go-to definition for health equity?  

Strengthening Hospital-CDC Partnerships – A new focus of MACDC

August 2nd, 2019 by Elana Brochin

Massachusetts hospitals devote millions of dollars annually to public health programs that serve their surrounding communities. As hospitals shift the focus of their public health programs towards upstream issues such as housing, education, and employment, it is important that they partner with organizations that are engaged in these areas, such as CDCs.

One of my roles as the Program Director for Health Equity at MACDC is to facilitate relationships between CDCs and their local hospitals. I view supporting these partnerships as building upon my previous role in which I worked to strengthen the state guidelines that direct many of these investments. The updated state guidelines provide the tools for hospitals to increase the transparency by which these investments are made and to increase community involvement in program planning and implementation.

Hospitals, as the institutions that ultimately control the focus of these investments, must commit to engaging community partners. While hospitals may have additional tools and incentives for engaging their community partners, many community organizations continue to find the procurement of hospital funding to be an opaque process. For a CDC, securing a seat at the table in which these investments are discussed is not an easy task. However, there are muscles that potential community partners can build in order to achieve successful partnerships with their local hospitals.

One way in which community organizations can learn more about the nuances involved in hospital investments is through trainings offered by the Mel King Institute for Community Building. Last March, the Mel King Institute held a training in which participants had a chance to learn about different types of hospital investments. For example, participants discussed the distinction between Community Benefits investments – which are annually budgeted for – and Community Health Improvement investments – which are episodically tied to capital expenditures.  Becoming well-versed in these different types of investments, is the first step toward meaningful conversations between CDCs and potential hospital partners.

This coming year, in partnership with the Mel King Institute, I will be introducing several trainings in which we will discuss the challenges associated with developing partnerships and continue to develop the language and the tools needed to initiate and deepen these crucial partnerships between CDCs and their local hospitals. The following are examples of topics that we’ll discuss in upcoming Mel King Institute Health Equity trainings:

Establishing a common language to talk about health equity
 CDCs must deepen their understanding of the pathways by which various social determinants of health (e.g., housing, employment, and education) contribute to health disparities. By establishing a robust vocabulary in which to have meaningful conversations with institutional partners CDCs will be better positioned to advocate for hospital investment in their work.

Deepening understanding of hospital funding

It is important to understand how community health programs fit into the complex hospital financing equation in order to better understand the role of community organizations in this process. Better understanding hospital financing is increasingly important as the system changes, such as the trend toward shifting from the pay-for-service model to Accountable Care Organizations.

The importance of long-term partnership building

 It is not surprising that small- and medium-sized community organizations become interested in partnering with hospitals when they hear of potential funding opportunities. Partnerships, however, rarely originate from a grant opportunity. Organizational relationships must be cultivated long before an opportunity becomes available. It is for this reason that CDCs must cultivate relationships with hospitals independent of a specific funding opportunity.

Keeping track of individual investment opportunities

CDCs must devote time and resources to keeping track of opportunities. This can mean there is a lot to keep track of: in many areas of the state, several hospitals serve the same region and the timeline for hospital investments vary by hospital and by type of investment. CDCs must have a mechanism for learning about funding opportunities as they become available.

What are questions that you have about cultivating relationships with your local hospitals? What challenges have you encountered? What would you like to learn about in this area?

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