July 2019, Volume XXXIII, No 4
Addressing health inequities
Bruce Thao, MS, MA
Director, Center for Health Equity and Office of Minority & Multicultural Health, MDH
Please define the term “health equity.”
The Minnesota Department of Health (MDH) defines health equity as: “A state where all persons, regardless of race, creed, income, sexual orientation, gender identification, age or gender have the opportunity to reach their full health potential without the limits of structural barriers.” This is from our 2014 “Advancing Health Equity in Minnesota: Report to the Legislature” (www.tinyurl.com/mp-mdh-equity).
Please tell us about the mission of the Center for Health Equity.
The Center for Health Equity’s (CHE) mission is to connect, strengthen, and amplify health equity efforts within MDH and across the state. Within MDH we serve as a consultant to the agency, providing training and technical assistance on how to embed equity into policy, research, and more. Externally across the state we connect and strengthen networks of health equity leaders and partners and administer the Eliminating Health Disparities Initiative (EHDI) grant program. CHE was created in 2014 and houses the Office of Minority and Multicultural Health, which has worked on Minnesota health inequities for over two decades.
You are part of a larger MDH initiative called the Center for Health Equity and Community Health. What can you tell us about this entity and how you interact with its different divisions?
Our division’s name and structure has recently changed. We are now the Community Health Division and are comprised of five different offices or centers: Center for Health Equity, Center for Health Statistics, Center for Public Health Practice, Emergency Preparedness, and the Office of Statewide Health Improvement Initiatives. Together we address health equity and community health from multiple perspectives, strategies, and with many partners across the state.
What are some of the biggest challenges you face?
Some of the biggest challenges are the numerous barriers to health equity, many of them beyond the scope of what CHE or MDH has the capacity or ability to influence or address. There is still much that we can influence, such as our internal operations and how we do business. Transforming the internal culture, policies, and systems within the agency has been the focus of our current five-year strategic plan and came out of recommendations from the 2014 report. MDH leadership agreed with community voices from across the state that in order to advance health equity externally, we first had to look internally.
Physicians play an integral role in advancing health equity.
While there is still much work to be done, there have been examples of phenomenal work across the state that is advancing health equity. Internally, one of the ways we have worked to spread awareness of this work is through a Health Equity Showcase, which brings the agency together to learn how divisions have embedded equity into their work. Our first showcase in February 2019 highlighted 12 programs addressing a range of statewide issues, such as food safety and food equity, sickle cell disease, breastfeeding, health equity data analysis, tuberculosis, radon testing, and more.
Externally, we have administered the EHDI grant program for nearly 20 years. This program continues to be a core source of funding to organizations and institutions that address health equity in American Indian communities and communities of color across the state. In that time we have seen the capacity of organizations doing this work grow and have seen shifts in health outcomes across the state. According to our most recent data, the current grantees have collectively reached one-third of the state’s populations of color and American Indians through their outreach and educational programming.
CHE’s work with the health care delivery system is through partnerships, training on health equity in Minnesota, and collaboration to think through how to best serve Minnesotans most impacted by health inequities. For example, our recent launch of a statewide Health Equity Leadership Network, comprised of over 100 cross-sector members, including many health care delivery systems, works on systems transformation to advance health equity.
The root causes of health inequity can be thought of through the same framework no matter where you live in the state. In the MDH 2017 Statewide Health Assessment (www.tinyurl.com/mp-mph-assessment), we talk about three things that influence health: opportunity, belonging, and nature. This is a helpful framework when thinking about different areas across the state and the specific challenges a community may face. Within CHE we’ve identified priority populations as populations of color/American Indians, rural communities, disability communities, LGBTQ communities, and low-income communities. This is based on data on communities most impacted by health inequities. We use these as lenses to frame our work. We know that these communities don’t live in silos—they have intersecting identities. We know that the more identities you have overlapping from these categories, the more you may be potentially impacted by health inequities. When thinking about challenges across metro areas or Greater Minnesota, we may change the primary lens we are using (in one community it may be about rural challenges; in another it may be access to services for disability communities), but we cannot lose sight of the other lenses and how they may overlap and compound inequities.
There are numerous studies and publications that can speak to the impact of social determinants of health on health outcomes. Clinical care only accounts for about 10% of health outcomes, while social determinants account for 40%. At our 2019 Health Equity Summit in March, over 200 health equity leaders from across sectors and communities came together to discuss the most pressing issues impacting our health. The number one priority identified was institutional racism. Things like housing, food security, and mental health were also named as important, but were lower on the list. While those factors are important to health outcomes, the group determined that root causes of inequities across sectors and systems are tied to institutional racism, historical trauma, and discrimination in its many forms. This echoes what we found in the 2014 MDH Advancing Health Equity report.
Until institutions acknowledge the impact of institutional racism, discrimination, and other forms of oppression embedded within our systems, policies, and practices, inequities will continue. The first step is acknowledgement and recognition. Next is looking within to assess how an institution’s internal workings may be contributing to inequity and what needs to change. This is the journey MDH has been on for the past decade, and we have only just scratched the surface. There have been significant strides, however, and we have begun to shift agency culture and are building greater trust with our partners in community, health systems, and across government agencies.
Physicians play an integral role in advancing health equity. Just as institutions must acknowledge how racism or discrimination show up consciously or unconsciously within systems or policies, individuals must do the same. This is deep work and requires new skills and training that most physicians do not receive in medical school. But the reality is that most of us do not ever receive training or naturally have the skills to navigate and address systemic inequities. It takes commitment and investment of time and resources at both individual and institutional levels. Yet the payoff is improved health for all—and isn’t that something we all want?
© Minnesota Physician Publishing · All Rights Reserved. 2019
Bruce Thao, MS, MA, is director of the Center for Health Equity and Office of Minority & Multicultural Health at the Minnesota Department of Health. Bruce holds an MS in psychology from St. Joseph’s University and an MA in social welfare from the University of Chicago. He is a 2013 Bush Foundation Fellow, a 2014 White House Champion of Change, and a 2017 Aspen Institute Scholar.