The world has never had better medicine. The benefits are not shared equally. Two years of data from the Centers for Disease Control and Prevention show that Black, Hispanic and Native American people are more likely to be hospitalized and die from COVID than white people in the U.S.
Health inequity includes the lack of access to appropriate care, the failure to address social factors that influence health, and the dangerous conditions that people in some neighborhoods endure. Equity requires campaigns on all fronts. A data-digging epidemiologist, an activist midwife, a doctor who traded clinic work for community activism and a pollution-tracking entrepreneur are some of the health-care champions.
Michael Marmot is a man.
Michael Marmot has spent his entire life working with data. He focused on cricket statistics when he was 12. When he was a student, he was a master of several branches of medicine. He was a physician in the 1960s in Australia. As if they were a data set, Marmot was fascinated by what united or differentiated them.
Millions of other physicians would eventually be influenced by Marmot's mindset by inspiring tools to identify the social determinants of health. There was no framework back then, and it was thought that social conditions were out of the reach of doctors. When he thought about the immigrant mother who was abused by her husband and struggled with chronic pain, and the young woman who had a difficult childhood and now experienced depression, he wondered: Why treat people and then send them back into the situation that made them sick?
At the University of California, Berkeley, Marmot pursued a PhD in 1971 to study coronary heart disease. At the time, textbooks blamed it on behavioral factors such as diet and smoking, but Marmot believed stress and social factors contributed as well. The men with the most Westernized lifestyles had rates of CHD three to five times higher than the men with more traditional Japanese lifestyles.
The health of British civil servants was related to factors such as income and job satisfaction according to his studies. The lower employees were more likely to die from heart disease.
Over the next 30 years, Marmot was able to accumulate more data. National wealth, income inequality and access to education are the strongest predictors of health for adolescents. The phrase "social determinants of health" was established and legitimized by his work.
How physicians, public health experts and governments think about health inequity has changed. He was asked to investigate health gaps by the U.K. secretary of state for health. The review found that injustice degrades the health of nearly all U.K. citizens and is preventable.
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Because of the influence of Marmot, physicians today can talk about social conditions and address them through community partnerships.
The University College London Institute of Health Equity is headed by Marmot. His work has been cited hundreds of thousands of times. His Review has spread from the eastern Mediterranean to Manchester. He says that health equity comes from greater equity in society.
There is a person named Shafia Monroe.
Black infants were more likely to die than babies of any other race, according to a startling fact learned by a teenager in Boston in the 1970s. She remembers thinking that there was no need to address the disparity in the scientific community.
This early knowledge led to a lifetime of work in expanding access to doulas and midwives for Black mothers. Monroe was the mother of the Black midwives movement.
Black women are more likely to die in childbirth due to being misdiagnosed, mistreated and stigmatized in health care. Monroe realized that if more Black mothers could get one-on-one birth support from other women, it would be better.
She knew that Black women wanted support from other women of color, and she had not yet had empirical proof. Monroe started working with similar professionals from other countries after founding the nonprofit Traditional Childbearing Group. They provided breastfeeding information and supported at- home births. The Massachusetts Department of Public Health started funding their work in 1988.
Research has supported her observations. Second-time mothers with support from a doula had a lower rate of cesarean deliveries. A small study found that women with the help of a doula had lower rates of preterm birth and low birth weight infants.
Monroe launched the International Center for Traditional Childbearing in 1991. She helped Oregon pass legislation that reimbursed doulas. Other states are following suit.
Arline Geronimus, a research professor at the University of Michigan Population Studies Center, says that community-competent and culturally competent doulas can help make the labor room safer for a birthing woman. She praises the ICTC for training doulas who are more likely to be trustworthy to women of color, as well as its policy work to allow those with low incomes to access doula services.
Black infants are 2.3 times more likely to die than white infants, and Black women are 3.5 times more likely to die of pregnancy-related causes. Monroe continues his work through actions such as advocating for an Alabama bill to expand access to traditional midwife care, as well as mentoring others fighting for birth justice.
Vera Cordeiro is a person.
Vera Cordeiro founded one of the world's most influential health programs, but as a child she didn't want to go to medicine. She loved art and literature, spending her days writing poetry in her treehouse and reflecting on the way she, born into a wealthy family, experienced life differently from her neighbors.
After family pressure, Cordeiro went to medical school and met a professor who was equally interested in people. If someone died of a heart attack, the professor would encourage his students to consider how the patient&s marriage or job affected their illness. In 1988, while working in a hospital, Cordeiro saw how medicine and life intersect.
We would treat a child for pneumonia, but then we would send her back to a house where she could not eat or her father was unemployed, and then she would come back with a different disease. She started asking her patients non medical questions, such as whether they had food or clean water, and she called on other medical professionals and friends to help them.
In 1991 she founded a formal organization called Associa de Crian de Crian at the hospital. Through the association, doctors can screen for poverty, unemployment, housing issues and other root causes of disease, and volunteers help to fulfill those needs with money, food and other resources. The teams help the parents set long-term goals for their children such as access to food and training for a stable job.
James Habyarimana of Georgetown University is a public policy professor specializing in health outcomes. He praises the organization for being aware of how poverty affects other dimensions, such as housing, which affect a child's health. He thinks it could be done in all of the world's poor areas.
Habyarimana found that children who were in the program were less likely to need surgery. Their stays were shorter if they were hospitalized. At the beginning of the program, 56 percent of families identified their well-being as bad or very bad, but by the end, 51 percent reported it was good or very good.
The organization has grown rapidly because of that success. It has inspired 20 programs in Africa, Asia and Latin America. The University of Maryland has been adapting the methods of Dara to its local context.
The person behind the disease is still being fought for by Cordeiro, who is now 71. She shows before-and-after photographs of houses that have been renovated, allowing families to live with more dignity in their homes.
Davida Herzl is a person.
Growing up in southern California, Davida Herzl used to look out to the Port of Long Beach to watch the container ships come in. She wondered how the emissions of the ships affected the people living nearby.
Herzl created a system to prove that poor neighborhoods have poor air.
She says that the social justice component of her work began when she was a multiracial Jewish girl with a belief that everyone is entitled to clean air. She found a way to act in 2008. A landmark study published that year linked air pollution with premature mortality and a range of illnesses, including asthma, respiratory infections, lung cancer and heart disease. The research found that the consequences disproportionately affect communities of color.
The person in Herzl emerged. Stakeholders didn't know how to address the problem because they didn't have the data. Aclima is a technology company that uses sensors to measure air pollution and greenhouse gases at the hyperlocal level. Aclima creates high-resolution air-quality maps by showing where carbon dioxide or carbon monoxide is concentrated.
Aclima has collaborated with governments and local organizers to create data maps. NASA, the U.S. Environmental Protection Agency and Google used Aclima sensors on Street View vehicles to carry out a comprehensive air-quality analysis in Denver. In San Diego, a similar effort found high concentrations of fine particulate matter and black carbon in communities with busy border ports. Poor cognitive function and lung and heart problems are associated with those two pollutants. A block-by-block analysis of West Oakland found that Marcus Garvey Commons had the highest levels of nitrogen dioxide in the area, where some of the highest poverty rates in the Bay Area are found.
David Reichmuth, senior engineer at the Union of Concerned Scientists, says that the work being done by Herzl with local organizations is important because it helps to identify which communities should be prioritized when creating policies to reduce pollution exposure. African Americans and Asian Americans are exposed to more pollution than white people in California.
The West Oakland Environmental Indicators Project used Aclima's air-quality analysis to create a plan to reduce emissions.
Herzl says that with these and other initiatives, data lead the conversation. What are we going to do about it?
An editorially independent special report that was produced with financial support from Takeda Pharmaceuticals includes this article.
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