Health Equity: Is There a Paradigm Shift Underway?

Spurred by the most recent PEN #PatientChat on Twitter, on Nov. 13, 2020, it felt like a good time to explore what appears to be a paradigm shift in the American healthcare system toward health equity. The phrase paradigm shift was coined by philosopher Thomas Kuhn, forming the core of his magnum opus, “The Structure of Scientific Revolutions,” published in 1962 and still widely referenced in all kinds of places, including my good buddy e-Patient Dave deBronkart’s work.

2020 has been a year with many surprises – “surprises” in the sense of “oh good grief what now?” – with one of the most welcome being what looks like an actual shift in thinking within the healthcare system that health equity actually needs to be a thing, versus just “a thing we talk about at meetings.”

The CDC defines health equity as every person having the opportunity to live at their full health potential, with no one disadvantaged from achieving that potential because of social position or other socially determined circumstances. In other words, your social determinants of health should be the same as everyone else’s, no one should be left behind in that “life, liberty, and the pursuit of happiness” deal due to economic or cultural differences. That’s health equity.

The signals I’m seeing in the health policy and health system design and delivery circles I hang out in on an average day are strongly indicating that the ivory towers of our healthcare system have started to wake up to how very inequitable our health system has been, historically. In my lifetime, I’ve seen countless groups earnestly discussing this issue, doing what I call “admiring the problem” without any clear framework for a system-wide fix. But the times, they are a’changing?

Some of the strongest signals I’ve seen:

• Health Affairs, the peer reviewed journal that the Washington Post calls “the bible of health policy,” published a post by editor in chief Alan Weil, “The Social Determinants of Death,” where he said, “It is not enough for health care institutions to stand against racism or with those who protest it. The test of the day is whether those institutions will use their power to fight racism. Will they cede wealth and power accumulated over decades to those who have been excluded? Will they engage in meaningful dialogue designed to break down barriers to a well-functioning society—one in which people engage in authentic relationships and learn of their shared humanity? If no one else is leading that dialogue, will they initiate it and include others as equals? Will we?”
• The American Heart Association put out a call to action on racism, noting that the COVID-19 pandemic had made health inequity all too visible in the impact of the pandemic on communities of color, and specifically mentioned the police killings of George Floyd, Breonna Taylor, and multiple others as reminders of systemic racism in America. “Several principles emerge from our review: racism persists; racism is experienced; and the task of dismantling racism must belong to all of society. It cannot be accomplished by affected individuals alone.”
• The American Academy of Pediatrics published a guide on how to talk to children about racial bias, noting that “parents may better face today’s challenges with an understanding of how racial bias works in children, as well as strategies to help them deal with and react to racial differences.”
• The American Medical Association announced a policy recognizing racism as a public health threat, including “the new policy requests AMA to identify a set of best practices for health care institutions, physician practices, and academic medical centers to address and mitigate the effects of racism on patients, providers, international medical graduates, and populations. It also guides the AMA’s position on developing and implementing medical education programs that generate a deeper understanding of the causes, influences and effects of all forms of racism—and how to prevent and improve the health effects of racism.”
• AcademyHealth, a leading health services research organization, centered health equity and issues of systemic bias and racism in its 2020 Annual Research Meeting. They’ve announced a racial equity strategy for their work that builds on what the org has already started on diversity and inclusion, noting that the dual pandemics of COVID-19 and racism signal a clear opportunity to assess their own values and actions, and to spur values and actions in alignment with health equity across the health services research landscape. “The challenge for a field that sees itself as impartial and unbiased is how to act to confront the reality of systemic, embedded racism as well as other forms of discrimination and challenge our assumptions about exclusion and inclusion, and the very idea of ‘unbiased’ science.”

There’s an opportunity here for patient advocacy community leaders to take a look at who’s at our tables, and on our leadership teams. Commitment to diversity, inclusion, and ending systemic racism isn’t just something that the healthcare system needs to tackle – we all can do our part. I’ve committed to recommending BIPOC (Black, Indigenous, and People of Color) patient advocates for leadership opportunities, and to point out the lack of BIPOC people in any advocacy group I’m part of, if that’s the case.

“Nothing about us without us” means ALL of us. Let’s work together to make this paradigm shift deploy fully.