HEALTHCARE

A basic principle of public health is that all people have a right to health care. 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.

Health Equity

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.8 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...”

Health inequities are not naturally occurring. 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. One thing is without question; the data and research are clear that is a systemic and ongoing public health crisis with serious consequences for Black that shape our health. This includes our healthcare delivery systems, education, economic, environmental, criminal justice, and political systems, among others.

Health Disparities

Health Disparities, on the other hand, are the health‐related outcomes 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 define a number of groups of people who are not usually well provided for by healthcare systems, is used to have poorer, access to healthcare, experiences and health outcomes than even the most vulnerable of our population.

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.

The blatant and persistent inequities in the delivery of health care have spawned a new partner in the battle for equal access. The call for health justice is one properly combined with that of health equity, using the force of law to provide the underlying legal support necessary to ensure the full and equal distribution of those social resources required to facilitate the elimination of health disparities. In fact, while this concept also considers the legal system to be complicit in the perpetuation of inequality by the enactment of laws that perpetuate poor health, it strongly advocates for the use of civil rights laws to enforce a “healthcare for all” model. For the purposes of this document, Health Justice theory states that health equity can only be achieved through the equitable distribution of the benefits and burdens which exist in the healthcare system.

The purposes of this Health Care Equity Plan:

1. To better educate the community regarding the inequities in the delivery of health care that serve to disenfranchise those most vulnerable residents‐those who are Black/Brown and poor.

2. To illustrate why a “Health in All Policies” (HiAP) methodology is critical to the elimination or significant reduction of disparities in the health care system. HiAP is a collaborative approach to improving the health of all people by incorporating health care considerations into decision making across multiple sectors and policy areas.

3. To identify those health‐related concerns in our community that require immediate attention and to present strategies that help to focus the work and commitment to transformation, required for the success of this initiative.

4. Ultimately, to provide suggested pathways toward the elimination of the barriers to Health Equity and Health Justice for everyone.

Racism and the inequities it creates are well documented as drivers of health disparities and overall poor health in the Black and Brown communities. 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.

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 in Health Psychology lab at the University of Southern California.

The toxicity of lifelong exposure to discrimination has been found to impact health in general and neurologic health in particular.

Several studies have shown a clear biological link between poor health outcomes and racism, even after controlling for other factors that might serve as proxy; access to health services for example.

In fact, health maladies including high rates of infant mortality, hypertension, and heart disease. The presence of these illnesses and other co-morbidities renders Black and Brown people more vulnerable to illnesses like COVID‐19, shortens lifespans and increases medical complications 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 Sclerosis that “Black people don’t get MS) to disparities in the way illnesses are. For example, Black and Brown 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 the reports of pain from Black and Brown patients, wrongly believing that Black and Brown people in particular have higher pain thresholds. This, according to Wilkerson, has led physicians to undertreat or deny pain medication to Black and Brown patients ‐ even those with metastatic cancer ‐ while readily prescribing severe medication to White patients reporting equivalent levels of pain. The disparity is so severe that Black and Brown people as a group receive pain medication at levels beneath the threshold by the World Health Organization.

California Surgeon General Dr. Nadine Burke Harris is a pediatrician who has studied the health effects of childhood trauma and stress. Dr. Burke Harris identified the long environmental and racially tinged experiences of Black and Brown people to be a major the higher rates of COVID‐19 in those communities. We (this country) have created differences— and they are literally leading Black and Brown people to die in far greater than others” she said.

The Health in All Policies methodology should be strongly considered in developing the policies and practices required for the implementation of this plan. Health in All Policies (HAip) is a collaborative approach that integrates and articulates health considerations into policymaking across several sectors intended to improve the health of all communities and people. HiAP recognizes that health is created by a multitude of factors beyond, the scope of traditional public health activities. Undeniably, factors associated with Social Determinants of Health, serve to shape not only the quality of lives of those in our community but also their health status. Using a HiAP framework for the implementation of this plan allows for healthcare to be in the forefront of policy and decision making while supporting the seamless integration of both health equity and health justice concerns.

1. Promote health, equity, and sustainability. Health in All Policies promotes health, equity, and sustainability through two avenues: (1) incorporating health, equity, and sustainability into specific policies, programs, and processes, and (2) embedding health, equity, and sustainability considerations into government decision‐making processes so that healthy public policy becomes the normal way of doing business. Promoting equity is an essential part of Health in All Policies.

2. Support intersectional collaboration. Health in All Policies brings together partners from many sectors to recognize the links between health and other issue and policy areas, breaks down silos, and builds new partnerships to promote health and equity and increase government efficiency. Agencies that are not typically considered as health agencies play a major role in shaping the economic, physical, social, and service environments in which people live, and therefore have an important role to play in promoting health and equity. A Health in All Policies approach focuses on deep and ongoing collaboration, rather than taking a superficial or one‐off approach.

3. Benefit multiple partners. Health in All Policies is built upon the idea of “co‐benefits” and “win‐wins.” Health in All Polices work should benefit multiple partners, simultaneously addressing the goals of public health agencies and other agencies to benefit more than one end (achieve co‐benefits) and create efficiencies across agencies (find win‐wins). This concept is essential for securing support from partners and can reduce redundancies and ensure more effective use of scarce government resources. Finding a balance between multiple goals will sometimes be difficult, and requires negotiation, patience, and learning about and valuing others’ priorities.

4. Engage stakeholders. Health in All Policies engages a variety of stakeholders, such as community members, policy experts, advocates, members of the private sector, and funders. Robust stakeholder engagement is essential for ensuring that work is responsive to community needs and for garnering valuable information necessary to create meaningful and impactful change.

5. Create structural or procedural change. Over time, Health in All Policies creates permanent changes in how agencies relate to each other and how government decisions are made. This requires maintenance of both structures which can sustain inter‐sectoral collaboration and mechanisms which can ensure a health and equity lens in decision‐making processes across the whole of government. This can be thought of as “embedding” or “institutionalizing” Health in All Policies within existing or new structures and processes of government.

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 Lorain County face significant challenges.

- Ohio consistently ranks among the bottom half of states on measures of health and wellbeing. For example, Ohio ranks 38 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 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 and Brown 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 color, such as higher rates of infant mortality and premature death.

- Black and Brown women 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, while the overall proportion of teens reporting suicidal thoughts or plans declined all racial and ethnic groups during the study period, the proportion of Black teens surged by 73%.

- A Centers for Disease Control and Prevention report found that Black and Brown women are about three times more likely to die from causes related to pregnancy, compared to White women in the United States.

- In Cleveland, Ohio Black and Brown babies are dying at a rate of 7 times that of White babies. Generally, in Ohio, Black and Brown infants die at a rate of 2‐3 times that of White infants.

- Black and Brown 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)

- Black and Brown people 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 co-morbidities.

- Food insecurity in Ohio has nearly doubled from 13.9% to 23%

- In Ohio, more than one‐in‐six older adults (17.6% ) 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 The Center for 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

According to the 2019 Lorain County Community Health Assessment (CHA) and the American Community Survey 5‐year estimates, the cities of Elyria and Lorain experience a larger burden of poverty, alcohol and drug use, chronic disease, smoking, and uninsured rates, compared to the rest of Lorain County, all of which are strongly linked to other poor health outcomes, specifically a higher infant mortality, low birth weights, and preterm births. According to the County Health Rankings, Lorain County has 312,964 people, and is the ninth largest county in Ohio. The cities of Lorain and Elyria contain 118,000 people, who are more likely to be of a racial/ethnic minority and experience worse health outcomes related to the social determinants of health like housing, employment, and educational attainment, and low access to healthcare due to limited or no insurance coverage.

RACE

Almost 15% of Elyria residents are Black compared to 9% across Lorain County. The median household income in Elyria is nearly 30% lower than the median income of Ohio and only 58% of housing units are owner‐occupied. More than 22% of Elyria residents live in poverty, compared to the county average of 13.5% and the current unemployment rate is 5.2%. 16% of Elyria residents have a Bachelor’s degree education or higher, compared to Ohio's rate of 26.6%, and 86.7% of residents have a high school diploma. In the city of Lorain, 16.2% of residents are Black and 28.3% of residents are Hispanic/Latinx. As for key indicators for the social determinants of health, 57.9% of housing units are owner‐occupied, 82.4% of residents have a high school diploma, the unemployment rate is 6.5%, and 26.2% of residents live in poverty.

CHRONIC CONDITIONS

According to the 2019 Lorain County CHA, 16% of Elyria and city of Lorain adults have been diagnosed with diabetes, compared to the county (13%) and 40% have a BMI >30 (obese) compared to the county (38%). Only 66% of adults from Elyria and city of Lorain visited a primary care provider in the past year compared to the county (71%). These adults were also more likely to have been diagnosed with high blood pressure (44%) and high blood cholesterol (36%) compared to the county. While the 2019 Lorain County CHA does not provide reports on city‐ specific health data on all topics, there is stratification done between rural, urban, and suburban communities. The city of Lorain and Elyria are considered urban communities. In urban communities, 13% of respondents did not have healthcare coverage, compared to the county (11%) and state (9%). 36% percent of respondents rated their health as excellent or very good, compared to the county (49%).

PREGNANCY AND BIRTH

From 2014‐2018, the smoking rate (at any point during pregnancy) among pregnant Black people in Lorain County women was 195.4 per 1,000 live births: 68% higher than that of Ohio. During this same period, the maternal smoking rate among pregnant Hispanic/Latinx women was 126.7 per 1,000 live births; White women smoked at 170.8 per 1,000 live births. During 2014‐ 2018, the average percentage of births among Black mothers who had a BMI >30 (obese) was 36%; compared to 30.7% of Hispanic/Latinx mothers, 27% of White/Caucasian mothers who gave birth during this period.

When observing health disparities in 2016‐2020 rates of preterm births among women living in Urban areas (city of Lorain/Elyria/Oberlin), vs. suburban and rural communities, we found further justification for focus on the primary and secondary populations identified above. Disparity between preterm birth rates among White and Black families is higher in urban population when compared to suburban/rural population. The preterm birth rate per 1,000 births among Black families in urban areas was 147.3 and in suburban/rural areas was 96.6. The preterm rate per 1,000 births among white families in urban areas was 106.3 and in suburban/rural areas was 88.4. Finally, the preterm rate per 1,000 births among Hispanic/Latinx families in urban areas was 113.9 and in suburban/rural areas was 114.8. This data illustrated that for both Black and White families, preterm birth rates are higher for people living in city of Lorain and Elyria. While for Hispanic/Latinx families, there was little difference in preterm birth rate based on geographic location, but rate is always higher than White counterparts.

These same families may also be affected by inadequate prenatal care as defined by the Kotelchuck Index. While the rate of inadequate prenatal care isn't as high as the urban areas, the disparity between income status is much higher in suburban/rural areas. Low‐income Medicaid recipients of any race/ethnicity have over a 2X higher rate of inadequate prenatal care than private payers in suburban/rural areas. Medicaid recipients have an 86% higher rate of inadequate prenatal care in urban areas compared to those with private payers. The larger disparity is also reflected in the preterm birth rate (while not as dramatic). Medicaid recipients in suburban/rural populations have a 15% higher preterm birth rate when compared to private insurance. This disparity is only 12% in urban populations.

We are losing a generation of Black men in America. Black men 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.

Black men live 7 years less than men of other racial groups. They have a higher death rate than Black women for all leading causes of death. Black men suffer more from preventable diseases that are treatable, have a higher incidence of diabetes and prostate cancer. In Lorain 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.

Recommendations

1. Incorporate “Health in All Policies” (HiAP) methodology in all areas of social determinants of health. The result of the utilization of the HiAP approach will be health, equity, and sustainability. Additionally, the engagement of stakeholders in true collaborative efforts will drive effective change. 


2. Engage Black and Brown people in the development of programs to serve the Black and Brown communities. Here, we underscore the critical nature of involving every level of the Black and Brown communities in planning from the outset. Understanding what will impact a community requires meaningful input from those same communities. To achieve Health Equity, authentic collaboration, transparency, and diversity is not an option, but a requirement. 


3. Highlight the availability of services as well as stressing personal responsibility. In our community, a wide range of services are being offered, yet Black and Brown people continue to suffer health‐related challenges at a much higher rate. For many, these are conditions that can be addressed through healthier eating and engaging in physical activity. Greater access to and visibility of fresh, healthy food and access to exercise programs and resources must be made available and accessible through community programming such as the mobile food pantries offered by Oberlin Community Services and El Centro de Servicios Sociales. 


4. Identify ongoing Implicit Bias trainings that health care workers must attend; increase workforce diversity overall in the Health Care System, and inspire all community organizations (board members, leaders and employees) as well as community members to engage in Implicit Bias trainings to help dismantle racism at all levels of the Health Care System. Concurrently, it is imperative that the health and human service providers across geographical areas communicate and collaborate to maximize available services and resources to serve the Black and Brown communities. 


5. Devise a strategic plan for improving co‐morbidities for those in the Black and Brown communities who suffer from conditions such as hypertension, diabetes, high cholesterol, cardiovascular disease, COPD, and obesity. The plan must include a wide variety of points of emphasis including, but not limited to healthy eating, active living, engaging in preventive screenings, the elimination/reduction of tobacco and alcohol products through available cessation programs, encouraging regular medical check‐ups and increased consultations with a family doctor. It is important to note that attention must be placed on the often‐ overlooked barrier of transportation as public transportation is a primary means of getting to work, going to medical appointments, and even for grocery shopping. Without access to transportation, many of the tactics outlined above will fail.

6. Confront and address infant mortality rates in the Black and Brown communities. At every level (federally, state‐wide, and locally), the infant mortality rates among Black people well exceeds that of other races and ethnicities. The keys to reducing these figures involve (i) educating Black and Brown mothers about proper care methods to be utilized and connecting them with proper available and affordable resources, (ii) tackling and resolving root cause concerns that Black and Brown mothers hold that preclude them from seeking appropriate health care services during pregnancy; (ii) providing effective training for health care providers on racism and implicit bias and (iv) developing a full continuum of maternal and infant care engaging all relevant types of providers. 


7. Address food insecurity and overall health. According to USDA, 22.5% of Black households are food insecure which is significantly higher than the national average of 12.3%. Lack of access to healthy foods results in a myriad of ramifications. Due to alarmingly high poverty rates in the Black and Brown communities, decisions are often being made to pay rent, utilities, and other necessities ahead of healthy food purchases due to limited resources. Specific tactics for addressing food insecurity include:

8. Increase daily access to healthy foods and fresh produce for children, adults, and seniors. This is critically important because presently, Black and Brown communities are often disproportionately surrounded by food deserts. “Food deserts” are an area where people do not have access to affordable and nutritious food. As such, unified and coordinated efforts to make public transportation, ride‐sharing and other manners of transportation available to residents will be vital. 


9. Educate children, adults and seniors about the federal programs designed to support those in need. A comprehensive and unified effort will increase access. These federal programs include the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants and Children.

* (WIC), Child Nutrition Programs (i.e., the National School Lunch Program, the Summer Food Service Program, the Child, and Adult Care Food Program with a focus on children and seniors to name a few).

* All these programs offer supplemental funding and benefits to parents as well as access to free nutritious meals for kids. For children, academic performance is directly related to poor nutrition (lower test scores, lack of sleep, increased tardiness, repeated grades, more absences, and behavioral instances that interrupt the learning day). As such, it is difficult to break the cycle of poverty when kids are set up to fail at an early point in their lives.

10. Identify and address Behavioral Health issues because it is a critical factor that contributes to overall health. We must work to ensure access to comprehensive, integrated mental health and addiction screenings and services for the Black and Brown communities including the promotion of early intervention measures. To experience any level of success with this, proper execution of programs and messaging strategies that reduce the stigma associated with seeking help for mental health and addition services in the Black community must be carefully crafted and deployed. Like the efforts being done at the statewide level, local agencies must work together to increase culturally meaningful screening, early intervention, and linkage to treatment and recovery services across the spectrum for mental and substance abuse disorders. (See COVID‐19 Ohio Minority Health Strike Force Blueprint.) This pandemic has highlighted the acute need for enhanced attention to be placed on the availability of Behavioral Health services. There has been sickness, death, job loss, uncertainty, financial challenges, racial unrest, and isolation. 


11. Provide more awareness and education about the importance of all vaccinations and the lack of vaccinations and their impact on all aspects of society. 


Inside of these efforts, however, we must pay particularly close attention to the increasing Black and Brown teen suicide rates and “cries for help” resulting from peer pressure, stress, domestic abuse at home, bullying and other triggers.

As noted above, a myriad of critical issues needs to be addressed all of which contribute to overall health. Some additional issues that will need to be addressed include (1) environmental issues that are alarmingly present in the Black and Brown communities with unsafe housing conditions or the presence of lead, for instance as well as providing clean drinking water along with other factors that can hamper or enhance one’s life; (2) combatting stress, violence, trauma and toxic situations, (3) providing effective, comprehensive services for Seniors and for individuals with disabilities, (4) contending with isolation due to COVID‐19 and especially for aging Seniors, and (5) dealing with the digital divide.

None of the above changes will be possible unless there is coordinated collaboration among service providers across the region along with a suitable increase in funding investments in the service organizations that render these indispensable services.