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Welcome to the blog for Health & Medicine. Founded in 1981, we're a 501(c)(3) nonprofit that operates as an independent, freestanding center driven by a singular mission: formulating health policy, advocacy and health systems to enhance the health of the public.


Apr 03, 2017 Written By: Tiffany Ford and Wesley Epplin

CPS, Health Equity, and Illinois’ Revenue Problem

As Chicago Public Schools (CPS) continues to struggle with budget cuts—and the system’s recent lawsuit about discriminatory education funding starts winding its way through the courts—we face another attack on our public education system and on Chicago’s youth. CPS leadership, along with Chicago and Illinois elected officials, share the blame for this failure. CPS budget cuts steadily chip away at investments in our collective future—our children—through reductions in teachers, necessary support staff, and outdated textbooks. These cuts worsen opportunity gaps, building on both historical and current structural racism and class inequity enacted through public policy, and are reinforced by our regressive state tax policy. This is an avoidable problem and we expect our elected officials to fix it.

Education is critical to the development of Illinois’ children and has a direct impact on health. Thus, inequitably funded schools are a public health crisis that exacerbates health inequities. Changing state tax policy so that Illinois can produce the revenue to equitably and sufficiently fund education is part of the solution.

Nationwide, Illinois consistently provides among the lowest state contributions to education, putting too much onus on local property tax revenue. This worsens education inequity by tying education funding to property tax revenue. High-poverty communities’ lower property value and associated taxes result in vastly lower education funding than in wealthy communities. This means that the schools attended by children born into poverty are systematically given less funding and resources than their affluent counterparts.  People of color disproportionately live in higher poverty areas, which is not incidental.  

Starting in the 1930s, predatory lending and property sales methods, such as redlining, restrictive covenants, contract buying, and blockbusting, made it especially difficult or impossible for communities of color to own homes and accumulate wealth. While officially outlawed in 1968, many argue that new iterations of these practices remain in use. Many other historic and modern examples of discriminatory policies exist, and together, they contribute to today’s residential segregation by race and class—and large differences in property ownership and value. Home ownership is also a major intermediate driver of the racial wealth gap, linking this history with vastly unfair education funding and opportunity today. If we believe in fair opportunities, Illinois elected officials must increase Illinois’ contribution to our schools to reduce the reliance upon property taxes for education.

This history of predation has a direct impact on our current education system and who is being disadvantaged by its broken and unfair funding structure. With regard to CPS specifically, the laws and budgets that contribute to education funding are systematically under-resourcing Chicago’s young people of color and people living in poverty. About nine out of every ten CPS students are students of color and 80% are economically disadvantaged students (meaning they come from families whose income is within 185% of the federal poverty line). Underfunding schools in which students of color and those living in poverty make up the majority of the impacted students is an example of structural racism layered with class inequity—perpetrated through public policy.

Recently, Health & Medicine provided recommendations to the Chicago Department of Public Health (CDPH) regarding measuring structural racism, which is available here.  A social epidemiology approach to understanding education inequities as they relate to health inequities requires both measures of the inequity in education outcomes and the causal drivers. To focus on redressing structural racism and class inequities shown in education outcomes, the field of public health needs to measure and understand the policy and budgetary drivers that cause insufficient and inequitable funding and resources both among Chicago schools and among districts in Illinois. Achieving education equity is a goal within the larger frame of achieving health equity in Healthy Chicago 2.0, making this a key issue for public health.

What’s the responsibility of Illinois lawmakers?  By failing to pass a budget and raise sufficient revenue, Illinois’ elected officials have abandoned all of our public systems, including social services, healthcare, and education. Our state’s per-capita government spending is among the worst in the country—we’re 37th. Illinois is one of only a handful of states with a flat income tax rate, among the lowest rates nationally. Taking into account both state and local taxes and credits together, Illinois has the fifth most regressive tax system in the nation. The flat income tax fails to raise enough revenue to share with municipalities, contributing to higher property and other taxes to fund services, such as education. These harmful and backward public policies have straightforward solutions.

Illinois needs a constitutional amendment to allow legislators to replace the flat income tax with a fair tax. The sooner we start down that road, the better. By failing to take this on, our elected officials are further locking Illinois into its losing situation of continued cuts to already sparse public investments. To pay down debts and equitably fund public services such as education—which benefit us all—we need revenue. Illinois needs a progressive income tax. It is the only way to move toward fair funding so that all children have equitable opportunities for education, which is necessary to contribute to society and live a healthy and fulfilling life—and for us to all benefit from their brilliance.

Mar 29, 2017 Written By: Sekile Nzinga-Johnson and Karen Loda

Fighting the Forces of Reaction: The Quentin D. Young Equity Project

On November 19, 2016 Health & Medicine launched a new initiative that honors the life and work of our organization’s founder, Dr. Quentin D. Young. Quentin was a life-long leader in social justice movements. The Quentin D. Young Equity Project (QDY Equity Project) aims to shape the next wave of progressive activists to build on his legacy.

The QDY Equity Project brings together people from different backgrounds and sectors to build relationships and explore new approaches to achieving an equitable society. Our goal through the project is to provide an opportunity for our participants to learn from their justice-minded colleagues in other fields, create lasting networks, question and analyze current approaches, and collaboratively create innovative and effective solutions to address barriers to equity. A key element of participation includes collaboratively learning, developing new forms of transdisciplinary knowledge, and further developing as intergenerational and inter-sectoral equity activists.

With the support of our Board of Directors and a committed steering committee inspired by the vision of this project, in the summer of 2016 Health & Medicine initiated recruitment for our first cohort of QDY Equity Project activists. The interest we received was overwhelming and we responded to requests for information from over 50 professionals from diverse sectors. As a result of this enthusiastic response, we ultimately decided to invite 31 participants to join our first cohort—an increase from the 20-member group we initially planned for.  Our final group is representative of the range of voices and perspectives needed to foster innovative solutions and includes diversity of gender, race, and age with participants ranging from those in their 20s to 60s, as well as a range of professional backgrounds including education, nursing, transportation, behavioral health, community development, and sustainable energy just to name a few.

Over the six-month pilot project, they will work together to explore a simple, but critical question, “How can we achieve social justice?”

The Launch
The group began working together this fall at a day-long retreat which began with energizing remarks from Janaé Bonsu, National Public Policy Chair for Black Youth Project 100 and Dr. Barbara Ransby, professor of History, African American Studies, Gender and Women’s Studies at UIC, and President of the National Association for Women’s Studies. After lunch and a discussion of the Ava DuVernay’s documentary, 13th  participants engaged in a cross-sectoral group exercise where they developed a six-month popular education based curriculum that they would collaboratively facilitate.

The diverse issues the group’s selected to discuss over the project include:
  • Climate Change
  • Whiteness
  • Health Access
  • Intersectionality of Immigration and Incarceration
  • Economic Justice & Workers’ Rights
  • Structural Segregation
After attending the launch, one participant shared, “My hope was to meet the other participants and learn what the first six months would look like. I also think I need to be re-energized and given hope post-election, and that definitely happened.”  

What We’ve Learned So Far

We are now at the halfway point of Equity Project pilot and are pleased to share that it been an enormous success thus far. After our launch, the group’s first session focused on Climate Change, taking a trans-disciplinary approach that connect this issue to the overall fight for equity. The participant-facilitators spent the day drawing connections between climate change and civil rights struggles. For example, they highlighted the case of high lead levels in the city of Chicago and how it disproportionately impacts communities of color. They also challenged their fellow participants to explore how they could confront food waste in their specific sectors and communities. One participant reflected, “Learning about climate change was interesting.  I haven’t thought about how climate change connects to social action or social organizing.”

The next session centered on “Whiteness.” The participant-facilitators invited Diana Dunn of the Peoples’ Institute for Survival and Beyond to conduct a two-part workshop on whiteness. The first workshop defined race and racism and the second workshop focused on white affirmative action. This session strengthened peoples’ understanding of racialization and structural racism and helped them to consider how the invention and maintenance of whiteness—and thus, white supremacy—has played out throughout history, and in their lives and work. One participant captured the group’s thoughts on our speaker, “[She] laid a great foundation for understanding racism as a way to maintain white supremacy and for shared definitions.”  

Our most recent session addressed Health Access. The participant-facilitators invited Dr. Claudia Fegan, board president at Health & Medicine and treasurer of Physicians for a National Health Plan to kick off the day. Dr. Fegan provided a comprehensive overview of the healthcare crisis in the US and offered a health equity perspective on the benefits of a single payer health care plan. The rest of the day included small group discussions on four areas of health access and equity—education, disability, abortion access, and mental health access–placing an emphasis on addressing the crosscutting themes that emerged throughout the day. One participant summed up the day’s highlights beautifully:

“The discussion on the “Single Payer” system was great. Learning how simple it is to establish and learning how much money would be saved by having this type of  system was interesting. I enjoyed the mental health and abortion talks the most. The speaker for the mental health group was open and shared his struggle with mental health.  He was excellent!!!”

The QDY Equity Project’s emphasis on popular education as a method to incubate inter-sectoral collaboration and action has been intentional.  Our participants have taken the lead in developing cross-cutting topics and facilitating sessions in ways that actively engage their peers across identities, sectors, and social movements. We believe this collaborative learning approach is particularly valuable at a time in our history when so many of our public policies, programs, and institutions are threatened. Health & Medicine’s Quentin D. Young Equity Project is responding to these threats by reactivating methods and models that have historically built broad based networks of solidarity that advance social justice, while also working towards innovative new solutions, and developing new models for change.

Interested in learning more about the Quentin D. Young Equity Project at Health and Medicine?

Stay tuned for updates on our final three sessions and the lessons we’re learned from our pilot project. We will also send out alerts when we are accepting applications for the 2018 cohort of the Equity Project. In the meantime, we will be launching a blog series called “Meet the Activist”, which will feature interviews with some of the dynamic people participating in our pilot!

Mar 24, 2017 Written By: Tiffany Ford and Wesley Epplin

Ending Police Violence is a Public Health Responsibility

Health & Medicine hosted a forum this past Friday, March 17th where presenters and attendees explored how public health can aid in prevention efforts and policy change toward counting police-involved injuries and deaths. Our discussion intentionally had a broad focus on decriminalization of people generally, and more specifically on people of color and people living in poverty. In light of this discussion and related inquiry surrounding our choice of topic and speakers, we drafted this blog post to help frame 1) police violence as a public health (and health equity) issue and 2) how we can move toward police accountability.

The United States has the highest rate of police-involved shootings and killings in the world, yet tracking both injuries and deaths from these interactions requires new surveillance and data collection systems. Although there have been recent efforts at the Federal level to improve the collection of data on arrest-related deaths, there remains a need for the U.S. to develop a system for collecting and transparently reporting data about both deaths and injuries from law enforcement. Also, there is a need for assurance that the data being reported is true and accurate. This data is needed as a matter of public accountability and for the purpose of advancing prevention.

This issue is particularly relevant as policing that disproportionately impacts communities of color and people living in poverty has spawned growing social movements and advocacy.  Healthy Chicago 2.0, the public health improvement plan for Chicago, identifies the reduction of mass incarceration and inequitable police attention in communities of color as a public health goal and priority for the city (found on page 65 of Healthy Chicago 2.0). Related to these efforts, Health & Medicine recently made recommendations to the Chicago Department of Public Health (CDPH) on measuring structural racism in Chicago. Measuring the degree of inequity in deaths and injuries resulting from the actions of law enforcement could help CDPH measure and work to prevent and address structural racism (and other isms) revealed in the data.

In the U.S., we have a public health system that reports on notifiable diseases and deaths occurring in over one hundred large cities nationwide. A notifiable disease (or condition) is any condition that is required by law to be reported to the appropriate governmental agency. According to a 2015 paper from social epidemiologist Nancy Krieger, the cumulative total of people killed by the police in 2015 significantly surpassed the number of people killed by myriad other notifiable conditions that public health professionals succeed at counting. To make the comparison clear: 842 people were killed by the police in 2015; 585 people were killed by pneumonia and influenza. The number of people killed by the police in 2015 was closer to the number of cases of Hepatitis A (890 cases), but Hepatitis A is a notifiable condition. The number of people being killed or injured by law enforcement is significant and deserves to be systematically counted.

Health equity is a process of assuring that all people have what they need to thrive as a means of achieving the goal of eliminating the systematic, unfair, and modifiable differences in health status and outcomes observed across different population groups. Discrimination based on race, gender, class, ability—both mental and physical—and age are evident in policing, arrests, violence from police, and in prosecution and incarceration all hinders health equity by disadvantaging those who are targeted. In addition to the immediate threat to health and freedom resulting from discriminatory policing, further disadvantages are often faced by those impacted through policies and practices that discriminate against individuals with criminal records in such areas as loans, housing, education, and employment.

Using an intersectional lens and applying the concept of sanctuary for all people, the forum discussion included the voices and experiences of those communities who have been historically over-policed and whose lives have often been disrupted—and health threatened—by the trauma of police violence. After much internal discussion, it is chiefly because of this trauma that the voice of the police was not included in this event. Last Friday, our presenters framed how the public health system could work to advance police accountability. This did not require the participation of police departments as speakers, although they were welcome to attend the event to listen and learn.

It is noteworthy that based on the existing data, the problem of law enforcement-related deaths and injuries is large and longstanding within the institution of policing, indicating a lack of accountability. Modern day police have been in existence in the U.S. since the mid-1800s. Given almost two centuries of existence, why haven’t the police figured out an accurate way of measuring injuries and deaths due to legal intervention? Why do we not have data that would help ensure an accountable police force?

Those are worthwhile questions to explore. In order to help find answers, public health professionals can do what we are well-equipped to do: count deaths and injuries stemming from police encounters.

Once police violence is required to be a notifiable condition, public health professionals have a responsibility for surveillance, monitoring, and control of the issue. The decision to not accurately quantify police-involved deaths and injuries is political in nature—as is the decision to do so.

If we care about the health of all people, including those being policed and law-enforcement themselves, then we, as public health professionals, should apply our skills and expertise in counting data on morbidity and mortality to the public health crisis of police-involved injuries and deaths in order to advance health equity.

Suggestions for further reading: APHA policy statement on law enforcement violence as a public health issue

Mar 07, 2017 Written By: Sekile Nzinga-Johnson

The Only Choice for Public Education and HBCUs is to Fund Them

Last week, Betsy Devos, Secretary of Education, drew a faulty and ahistorical connection by positioning historically black colleges and universities (HBCUs) as the "real pioneers when it comes to school choice".  Devos’ school choice agenda is not a viable choice for most Americans nor were HBCUs founded as an educational choice for Blacks who were systematically denied access to American colleges and universities. They each are representative of unjust policy agendas that disinvest from communities and intensify inequity.  Because I value education, I think the Secretary of Education might benefit from learning from a case study on the invaluable impact that a  public school education and a HBCU education has on the lives of many Americans, including my own.  

I attended public elementary, middle, and high schools in Providence, Rhode Island with students from poor, working, and middle class families.  My classmates were from a multitude of racial and ethnic backgrounds and many were immigrants and refugees. Attending well-funded public schools meant I did not have to pay for my books, school supplies, meals, field trips, health screenings, or transportation. My elementary school provided me with a viola for free when I began taking music lessons and my middle school provided me access to school-based performing arts programs. I also had access to school libraries and school-based nurses.  The allocation of state and federal funds to Providence public schools served as protective factors against the economic and racial inequity that I encountered daily as a Black working class student and contributed in innumerable ways to my growth and development. 

In 1989 I was accepted into Morgan State University, a historically Black University in Baltimore, Maryland. Morgan was founded in 1867 to provide pastoral education to Black men.  In 1939, under mounting pressure for not providing quality education to its Black population, the state of Maryland purchased the college.  Despite Morgan being chartered as a public state university, like other HBCUs, it has never received funding on par with white public colleges and universities.

I recall during my freshman year, my fellow Morganites and I staged sit-ins, blocked entrances to academic buildings, and marched at the state capital in Annapolis to demand equitable educational funding for our beloved university.  We were met by Maryland state police in riot gear with K-9 dogs.  Twenty-four years later, Morgan continues to confront underfunding at the state and federal level but it also continues to flourish as a world-class educational and research institution that I am proud to call my alma mater. 

Did I “choose” to go to an HBCU? Yes and No.

No, because my college “choices”—even after de-segregation—were still structurally constrained.  Blacks in the U.S. continue to be disproportionately poor and working class and many do not have the financial resources. The majority of HBCUs have historically been publicly funded and are relatively more affordable. My family’s working class status meant that I had to “choose” a university that was I could afford with the support from a grant from Road Island for college bound students, the Pell grant, work study, and federally subsidized student loans. 

Also, yes, my prior experiences with interpersonal and institutionalized racism within educational systems meant that I “chose” a college that affirmed my existence and had faith in my intellectual capabilities.

It’s important to note that my forced choice to attend an HBCU did not result in an inferior college education. To the contrary, Morgan State University’s classrooms and labs were filled with aspiring Black students just like me who deserved access to a quality college education. We were taught by brilliant and dedicated professors who were often overworked, underpaid, and who taught lessons and conducted research with fewer resources than professors teaching at predominantly white public institutions in Maryland. Yet, they gave us the critical analysis and foundation we would need to confront injustice and inequity in our lives, our careers, our communities, and our country. 

Charles L. Betsey, Economics professor at Howard University  and editor of Historically Black Colleges and Universities, notes that the 105 HBCUs still in operation account for three percent of the nation's educational institutions, but they graduate almost one-quarter of African-Americans receiving college degrees. Morgan State University’s professors’ commitment to my education contributed to me receiving a full fellowship to attend Ohio State University for my master’s degree and later, a full fellowship to attend University of Maryland-College Park for my doctorate. Eventually I became a social work and women’s studies professor, modeling my career as a social justice oriented educator and engaged scholar after my former professors at Morgan State University.  

I am sharing my personal educational journey to demonstrate what is possible when we invest in K-12 public education and to help others understand the indispensable role that HBCUs continue to play in educating  Black college students.  I realize I am but one example, but Betsy Devos, a major proponent of privatized education, is deeply misguided both in her understanding of what students need and which investments we should be making as a country.

Feb 22, 2017 Written By: David Fischer

Justice is, By and Large, Just Racist

This blog post is part of Health & Medicine’s “mythbusters” series which looks at common beliefs related to our work, providing data and context to separate fact from fiction.

Myth: Racism does not exist in our juvenile justice system.

Reality: The myth that we are holding youth based solely on their crimes fails to account for how Racism and other forms of oppression operate in the justice system.
In Illinois, our Juvenile Justice population is largely youth of color.* 

As we move further into an age of juvenile decarceration, the claim often made by politicians is that only the worst offenders are being held in secure confinement.  This can give us the notion that only those young people committing violent crimes—those that pose a “threat” to our community and safety—are being held in secure confinement.
But if that was the case, why are so many of the offenders held in secure confinement young, poor, and Black? The notion that we are holding youth based on their crimes hides the larger social inequities that become clear when we truly examine how Racism operates with other forms of oppression. 

When we look at arrest data, it would seem to support the claim that Black youth, while overrepresented in the justice system, are committing significantly higher rates of violent crime. However, when you look at self-report rates of violent crime, the numbers do not show the same level of disparity.  In fact, a national youth survey found that about 36% of Black males, 25% of White males, 18% of Black females, and 10% of White females reported committing a serious violent offense. The National Crime Victimization Survey found that 52% of aggravated assaults were committed by White juveniles, and just 31% were committed by Black juveniles.  The rates of robbery were almost flipped, so while Black youth were more likely to commit robbery than White youths, the total percentage of White youth offending (42%) and total percentage of Black youth offending (41%) are almost equal.

Despite nearly equal rates of committing offences, our justice system is disparate at every point, and the disparities grow as youth move further into the system.  An Illinois Juvenile Justice Commission report from 2010 data shows that, while Black and White youth commit crimes at nearly the same rates (and in fact, White youth report using and selling far more drugs), the juvenile justice system does not respond justly:

To address this, we as advocates, activists, and educators, need to move beyond the simple focus of changing individual communities and look at the systemic factors that lead to disproportionate minority contact (DMC). We need to focus the conversation on the ways in which Black youth are seen as inherently more dangerous, more “at risk,” and more in need of contact in the justice system. To move beyond this myth, we need to question the use of risk assessment tools that are biased in their assessment of risk, and to push back on people who suggest that mentoring will solve the problems facing youth in the justice system.

*Because data on Latinx youth is not collected, or collected differently by different systems, it is difficult to talk about disparities outside of a Black/White context, so for the purpose of this post, we will only focus on crime and justice involvement from a Black youth/White youth perspective.

Jan 31, 2017 Written By: Ann Duffy

Living our Values: Health & Medicine’s New Maternity Leave Policy

There's been a lot of talk lately about maternity leave policies in the U.S. We all know by now that America is behind the rest of the world when it comes to offering new moms (and dads) paid time off after the birth of a child. The Family and Medical Leave Act mandates 12 weeks of unpaid leave for new moms—but is applicable only to organizations with 50 or more employees.

I found out I was pregnant in November 2015, prompting me to read every news item related to maternity leave—many about how horribly we treat new moms in our society. So I decided it was time to try my best to update Health & Medicine's maternity policy.

I began by researching the policies of other progressive nonprofits. I was shocked at some of what I found. Organizations whose mission is based on helping women and children were totally lacking in support for the very mothers who work for them.

I saw the opportunity for Health & Medicine to be a leader in this area. Our mission is based on health equity, after all. So I began by answering any potential questions that might come up: How is a fair maternity leave policy an example of health equity? Can our small 15-person nonprofit afford it? How can I show that this proposal is not solely self- serving? Here was my reasoning:

1) It's what's best/healthiest for mother and baby.  It’s well known that breastfeeding is one of the most beneficial things you can do for your newborn. The American Academy of Pediatrics recommends exclusively breastfeeding your baby for the first six months of life, at minimum. Newborns can feed as often as every two hours, so if I needed to return to work too quickly, not only would that mean I’d be pumping milk on the train on my way into work, but also during phone calls, lunch breaks, and likely throughout most staff meetings. Instead, I’d probably just pump less frequently and as a result, see my milk supply dwindle and my baby therefore forced to start formula well before she ever would had I stayed home with her, adding to my already abundant guilt for not giving her enough tummy time.  

Bonding. Is there anything more important or natural than bonding with your new child? Evidence not only suggests that quality bonding in the first stages of life can decrease stress, but it can also have an effect on the child’s health, decreasing the likelihood of disease, and boosting immunity, and eventually leading your child to a better, happier life.  

And speaking of a happier life, our society shouldn’t punish families for having a child. Anyone who’s ever had to miss a few paychecks can understand the stress caused by a decrease in income.  

2) We should be a leader in this area.

Paid leave is slowly gaining traction in a lot of the country (cities like New York and San Francisco come to mind). I felt that Health & Medicine take the lead on this issue since having a paid maternity/paternity policy is in line with our mission. It sends a message about what we care about. Other non-profits should be coming to us for advice on policy – not the other way around.

3) It is an investment in our staff and our future.

Good policies improve morale and decrease employee turnover. Studies have shown that employee turnover is more expensive than family leave resulting in costs like lost productivity during recruiting and training, cost to recruit, and we would very likely not have someone performing at my level by the end of three months. 

Also, maternity/paternity leave occurs rarely – it’s not (usually) a regular occurrence.
Having good personnel policies helps organizations recruit and retain better employees. For some people, weighing the benefits and policies of different organizations is sometimes just as important as comparing salaries.

Just as paid sick leave and paid vacation are an investment in the wellness of employees and allow them to perform at their best, so is paid maternity leave.  Maternity leave is for having a baby and recovering from childbirth and should not be counted as sick or vacation time. Sick time should be reserved for when parents or their children are sick and they do not have childcare.  

If organization’s care about the wellness of their employees, they should not be penalized for having a baby. Not having your sick and vacation time can contribute to being overworked, spreading illness at work, and increased stress. Having new mothers use sick and vacation time contributes to gender inequity. It allows men to have this time to relax and recover, but not women. Not only are women paid less on average, they have to face this too?

I could go on but I thought I’d presented a strong argument for a policy change.

Health & Medicine agreed. In June 2016, I’m proud to say that we adopted our new maternity/paternity leave policy. Health & Medicine now offers 12 weeks of paid leave to new mothers and fathers.

In July 2016 I gave birth to a healthy baby girl. My leave ended this past fall and I can unequivocally say that our new policy made a huge difference in my family’s life – I felt ready to return to work on firm ground - as compared to when I took unpaid leave during the birth of my first child in 2012.

Honestly, 12 weeks is not enough. But it’s a start. And I’m glad that Health & Medicine decided to take the lead on this issue and live its values.

Jan 24, 2017 Written By: Margie Schaps

Setting the Foundation for Health Reform

Last week in honor of Martin Luther King, Jr. Day, Health & Medicine’s Executive Director Margie Schaps was invited to present on the future of healthcare at Northwestern University. Presenting to students from the Priztker School of Law and the Feinberg School of Medicine, Schaps offered an overview of historic roots of health inequities as well as the impact of the Affordable Care Act and directions for future work. We are pleased to share her presentation here.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.  So said Martin Luther King in 1966.

What King also taught us is that we must confront structural racism and the values of our institutions: that we must be “creative dissenters” and hold the country to a higher destiny—he was a wise man.

So today I hope to leave you understanding some of the underlying reasons for health inequities, why it is that people of color are disproportionately unhealthy, what laws and systems have been changed to address these inequities, what was in place before the Affordable Care Act, and what we need to continue to address if we want to eliminate health inequities.

To go back in history a bit, there have been some significant civil rights efforts that have addressed health equity, directly or indirectly. I am not claiming that we have fully realized the intent of these laws, nonetheless some of the most significant among them were:
  • 1954 Brown vs. the Board of Education assuring equal access to education—we know that poverty and education have the most significant relationship to health outcomes and life expectancy
  • 1966 Medicare and Medicaid assuring health care insurance for older adults regardless of income under Medicare, and certain groups of low income people, people with disabilities, and older adults under Medicaid
  • Ending the Jim Crow practice of segregating patients by race, allowing for all patients to have access to better hospitals and care
  • Ending practices of not allowing Black physicians to practice at most hospitals—a charge led by my mentor and a graduate of this medical school, and lifelong social and health justice advocate, Quentin Young
What we know about health inequities is that they arise out of structures we have set up as a society which then have an impact on the social determinants of health which then result in health inequities. So addressing all of the levels of policy to practice, not simply access to medical care, is the only way to fully address health equity for racial and ethnic minorities. The World Health Organization acknowledges that roughly 10-20% of health is a result of medical care; much of the other 70-90% is related to structural/institutional practices, social determinants, genetics, and individual behavior.

So what are structural factors?
These include things like education financing policies that benefit wealthier geographic districts, fair wage policies impacting personal income and income inequality, fair housing policies, and policing practices that disproportionately affect communities of color.

Social determinants are intermediate factors that impact health and include things like access to healthy food, green space, and social cohesion as well as environmental factors such as air quality and exposure to lead. When we put these together and lay them on top of each other on maps, the negative structural factors and social determinants pile on to racial and ethnic minority communities.  The communities with the most poverty are the ones with the least investment in schools, the highest drop-out rates, poorest housing, the greatest interaction with police and resulting incarceration…..and the greatest health inequities and disparities, the worst health outcomes, lowest life expectancy, and least access to affordable health care.

From a health care perspective, race remains a significant factor in determining whether an individual receives health care, whether he or she receives high quality health care, and in determining health outcomes.  In the 80s and 90s reports emerged describing poor health status and outcomes of African Americans and other people of color in the US.  Congress requested that the IOM study the differences in kind and quality of health care received by racial and ethnic minorities in the US. The IOM study culminated in the 2003 report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care in the US” and I recommend this report to all of you. The report made recommendations in the areas of policy, regulation, health systems reform, programs to enhance individual education and empowerment, research on racial and ethnic disparities and development of intervention strategies, and integrating cross-cultural training into training of all health professionals.

So how does this play out in real life?

Here in Cook County, data we have from before the ACA showed us that life expectancy in our highest Socio-economic (SES) status communities (nearly all white) is about 87 years, and in our lowest SES communities (nearly all communities of color) was 73.2 years—a difference of 13.8 years.

Life expectancy is directly correlated with level of education, and African Americans and ethnic minorities have generally lower educational attainment.  Furthermore, educational attainment is associated with health behaviors and outcomes including smoking rates, drug use, and obesity.  Poorer educational systems in poorer communities result in higher dropout rates, more criminal justice involvement, more poverty, and poorer health.

There is increasing evidence that discrimination itself has a negative impact on health outcomes—youth trauma and discrimination results in poorer health later in life and earlier death.  Nancy Kreiger, the Harvard epidemiologist, has shown a direct link between racial discrimination and elevated blood pressure and increased risk of cardiovascular events.

So where were we with regard to health inequities by race and ethnicity before the Affordable Care Act?

  • We know that about 46 million Americans had no health insurance and that the risk of being uninsured for Latinos was 36%, for African Americans it was 22%, and for whites it was 13%. We know that people of color without health insurance use the emergency room more frequently for less urgent issues than do whites, but we also know that they live in communities where their local hospitals are more likely to be closed.
  • Uninsured adults are at least twice as likely to go without a physician visit as whites and are more likely to be hospitalized for preventable conditions.
  • African American children had hospitalization rates for asthma  four¬ times higher than white children.
  • We know that infant mortality rates for Black college educated women was three times higher than for white women.
  • Breast cancer incidence rates in 2008 were 1.4 times higher for white women than Black women, yet Black women had a 41% greater risk of dying from breast cancer.
  • Quality measures for care for non-white populations were not getting better—at least half of core quality measures in this country were worse or the same.
Finally, I’d like to talk for a moment about the health care workforce, quality, and public health before the ACA.  There were major efforts in the  70s, notably the federally qualified health centers and the National Health Service Corps that made significant contributions toward increasing the numbers of health professionals and facilities in medically underserved areas, but:
  • Racial and ethnic minority groups were woefully under-represented in the workforce
  • Racial and ethnic minority health workers are more likely to live in neighborhoods lacking health resources
  • Very little data was being collected on patterns of use of health systems/quality/outcomes/and disparities
  • Investments in population health and public health were extremely low—investments we knew were key to uncovering and addressing health equity
The ACA addressed some of the issues I’ve laid out, but what I hope you leave here understanding is that to address health inequity, addressing health insurance access is just a beginning—an important one—but just a beginning. 

We must develop a workforce that reflects the population they are serving, invest in population health not just individual health, invest in addressing the structural policies and practices that underpin inequities, gain the trust and collaboration of communities most affected by disproportionate and unequal practices, collect data that shows progress and gaps, and develop programs and service in response to what the data tells us. We must disproportionately invest in our most under-resourced communities, break out of our siloes, and figure out how to create new solutions to persistent problems.

The challenges ahead are great, but as King himself said, the arc of the moral universe is long, but it bends toward justice. We can only bend this arc if we commit to doing it together.

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