Health departments placing stronger emphasis on equity: Achieving social justice in public health
=================================================================================================

* Kim Krisberg

*First in a series on health equity, which ties into the theme of APHA’s 2018 Annual Meeting and Expo: “Creating the Healthiest Nation: Health Equity Now.”*

Next month in Missouri, Kansas City residents will vote on a measure to require city inspection of rental housing. As Rex Archer talks about the proposal, he mentions a photo he has of a local rental unit with a hole in the floor so big a small child could easily fall through.

“I have the authority to take that property offline, but no authority to make a fix and we already have a shortage of low-income rentals,” Archer, MD, MPH, director of health at the Kansas City, Missouri, Department of Health, told *The Nation’s Health.* “But we wouldn’t have holes in floors if the landlords knew we could hit them with reinspection fees.”

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/48/5/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/48/5/1.3/F1)

Families are rescued from their Houston homes in August 2017 following flooding caused by Hurricane Harvey. Ensuring all residents are prepared for emergencies is part of health equity work in Houston and in health departments nationwide.

Photo by Erich Schlegel, courtesy Getty Images

Work to improve rental properties came in response to local health data showing 24,000 residents were living in substandard rental housing and often paying high rents to do so. After failing to get the inspection ordinance through the Kansas City Council, community organizers collected enough signatures to get the measure on the August ballot. If approved, the measure would empower health department inspectors to respond to hazardous housing complaints and issue reinspection fees for housing problems that go unfixed. A landlord fee of $20 per rental per year would support the new inspection system, with part of the revenue going to childhood lead poisoning prevention and to help tenants relocate if they are forced to move due to dangerous conditions.

“By identifying what the issue was, the community could exercise its right to improve resident protections,” said Archer, an APHA member. “It’s going back to what we used to do in public health — social movements, community organizing, addressing social issues.”

Data-driven public health policy has long been at the center of the Kansas City health department’s equity work, which began, in earnest, nearly two decades ago after data revealed a more than six-year life expectancy gap between the city’s black and white residents, with about half of the city’s annual deaths attributable to factors such as poverty, segregation, violence and lack of education. The data pushed the agency to begin the process of shifting its focus from health disparities to health inequities, with an eye toward remedying the conditions that confer greater health opportunity to certain populations over others.

After years of work, Archer said health equity values are part of everyday practice at the health department, with many of its equity wins driven by a mix of policy, partnership, data and community engagement. Just recently, for example, the health department successfully persuaded the city to adopt an official five-year business development plan that includes a strategic objective to increase overall life expectancy and reduce health inequities, with a goal of incentivizing development in neighborhoods in need of services and jobs.

“The most important competency in (health equity) is relationship building,” Archer said. “It’s asking ‘how do you empower and grow leadership in your community, how do you give voice to the voiceless?’”

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/48/5/1.3/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/48/5/1.3/F2)

Kellie Deagazio works on the nails of a customer while using a ventilator in Norwood, Massachusetts, in 2014. In nearby Boston, health officials are working to protect salon workers, some of whom are particularly vulnerable to workplace hazards because of their immigration status.

Photo by Joanne Rathe, courtesy The Boston Globe/Getty Images

As research increasingly shows a clear link between poor health, life expectancy and social determinants such as poverty, racism, housing and education, more and more public health departments are joining Kansas City in moving health equity from guiding theory to daily practice.

“I’m thrilled that the rhetoric has caught on — for many years it sounded very radical to talk about health equity and it doesn’t feel that way anymore,” Paula Braveman, MD, MPH, director of the Center on Social Disparities in Health at the University of California-San Francisco and a longtime equity researcher, told *The Nation’s Health.*

In 2011, the Centers for Disease Control and Prevention released its first “Health Disparities and Inequalities Report,” highlighting the effects of social determinants on people’s health and defining health inequities as a “subset of health equalities that are modifiable, associated with social disadvantage and considered ethically unfair.” CDC’s 2013 edition of the report recognized that “disparities are closely linked with social, economic and environmental disadvantage,” with then-CDC Director Tom Frieden, MD, MPH, quoting Martin Luther King Jr. and calling on public health to work with “the fierce urgency of now” to eliminate health inequality. The scientific literature on equity continues to expand, with researchers consistently finding an association among life expectancy, health status and social disadvantages such as poverty and discrimination.

In a 2014 article in *Public Health Reports*, Braveman, an APHA member, defined health equity as “social justice in health” and health disparities as the metric used to measure progress toward equity. She said a key competency for effectively moving toward equity is applying an equity lens across public health activities, which reminds staff to always be conscious that decisions can inadvertently widen disparities and to ensure that all people reap the benefits of public health intervention.

For example, Braveman noted that even as national smoking rates declined over the years, disparities in smoking rates often widened, suggesting that interventions were not reaching historically disadvantaged communities.

“What it really takes to pursue health equity in a serious way is addressing the social determinants of health and to do that, you have to have enlightened leadership and political will at the top,” she said.

## Health departments changing culture

Public health departments nationwide are working to tackle social determinants and advance health equity in their communities. In fact, research is beginning to show that public health workers who rate their department’s commitment to equity as high are also more likely to work across sectors and less likely to identify skill gaps.

“The big thing for us was that we needed to change the culture within our department — to really move from a mindset of disparities to the language of equity,” APHA member Umair Shah, MD, MPH, executive director of Harris County Public Health in Houston, Texas, told *The Nation’s Health.*

In 2013, the health department released its first five-year strategic plan that explicitly named equity as a core value, launching an internal effort to embed health equity as a daily practice. Shah said an initial step in that process was recognizing the need for workforce development, which eventually led to the creation of an equity training series, some of which all agency staff are required to take. The health department also hired a health equity coordinator and strategically headquartered its equity work inside the cross-cutting Office of Policy and Planning to optimize its reach throughout the agency.

Equity values are forcing staff to see traditional public health work with a new lens, Shah said. For instance, in the midst of Hurricane Harvey in 2017, Shah said it became clear that the agency had to gather data on much more than injury and illness — to support equitable recovery efforts then and in the future, data on upstream factors such as housing and transportation were needed as well. And emergency preparedness is just one area in which equity is having an impact.

For example, the agency’s health equity coordinator was embedded in its Zika response to ensure protective messaging reached the most vulnerable and that resources were available so all residents had the opportunity to act on that messaging.

Shah said the equity coordinator often joined mosquito control workers in the field to help identify neighborhood conditions that could inadvertently foster mosquito breeding. In food safety, Shah said equity training has fostered a deeper understanding of how to effectively partner with all restaurant owners in the diverse county, with inspectors often working with ethnically affiliated chambers of commerce to tailor safety messages.

“We understand it’s a long journey and we’ve only taken many steps in a long marathon, but we also recognize that it’s important to have meaningful wins along the way,” Shah said. “It makes complete sense that equity would drive this work because we have to be responsive to the demographics of our community.”

In Massachusetts, the Boston Public Health Commission is a relative health equity veteran, first starting such work in the early 2000s. Like Harris County, the first step was workforce development, with a pointed focus on racism, implicit bias and cultural competencies, according to APHA member Monica Valdes Lupi, JD, MPH, executive director of the commission. In 2011, the commission launched a mandatory two-day training on equity and racial justice for all new hires at the health agency. The agency has since trained more than 1,500 staff, including emergency medical staff and front-line responders.

“It’s about building internal and external capacity so communities are empowered,” Lupi told *The Nation’s Health.*

Earlier this year, for example, the commission awarded its second round of financial assistance to help local nail salons come into compliance with new workplace ventilation rules designed to protect salon workers — some who are particularly vulnerable to workplace hazards due to their immigration status — from chemical exposures linked to adverse reproductive effects, asthma, skin irritation and certain cancers. Lupi said the funding has gone a long way in brokering better partnerships with community stakeholders who have a role in creating healthier, more equitable conditions.

Cross-sector work and data are central to Boston’s success, said Margaret Reid, RN, MPA, director of the commission’s Office of Health Equity.

“We’re the most income-inequitable city in the country and the third most expensive for rental housing, so to succeed we have to work with other sectors,” she said.

Lupi said stratifying local health data by social determinants has been a key engagement tool.

“Data plays an important role in terms of the narrative we tell and in helping people see that good health isn’t borne out equally,” she said. “Being able to show the (inequities) in the data we have is pretty remarkable.”

Across the country at the Santa Clara County Public Health Department in California, health equity had long been a guiding objective, “but we weren’t able to get really serious and down to brass tacks until 2015 when we made it a strategic priority,” Sara Cody, MD, Santa Clara health officer and director of the department, told *The Nation’s Health.* Like its colleagues across the country, the new journey began with workforce development.

“We knew we had to get our own house in order to have conversations about equity,” Analilia Garcia, DrPH, MPH, senior health care program manager for racial and health equity at the Santa Clara health agency, told *The Nation’s Health.* “We had to build a shared understanding and shared analysis of why we were making a commitment to lead with race.”

The agency convened an internal committee that developed training workshops for staff covering racial and health equity basics, structural racism 101, LGBTQ health and cultural humility and competency. The agency’s nearly 500 workers are about halfway through the peer-to-peer training series.

Cody said the training experience has been an “empowering” one for public health workers, providing them with a framework for tackling a daunting problem and creating shared understanding across staff. Next up, she said, is operationalizing equity into everyday practice.

“We have a role, a moral obligation and a responsibility to understand (inequity) and not further perpetuate it,” Garcia said. “It’s understanding the context we work in — understanding our place.”

At the Department of Health and Human Services in Evanston, Illinois, just north of Chicago, community engagement is the core of the agency’s health equity work.

“When you ask someone not ‘What can I do for you?’ but ‘What happened to you?’ then you can really understand the impact that racism has had in our society,” Evonda Thomas-Smith, RN, MSN, director of the Evanston health agency, told *The Nation’s Health.* “Instead of telling the community what they need, we listen and ask them what they want. That’s a very different conversation than we’re used to having in public health.”

To drive equity forward, Thomas-Smith said the health department has committed to letting the community lead, even if it means upending the usual course of action. For the first time, for example, the agency has embarked on a participatory, priority-based budget approach in which community members are invited to take part in deciding how the health department should allocate its resources. As of May, the agency had hosted 10 such budget meetings throughout the community. Like its fellow health departments, the Evanston agency has also gone through workforce training and is now operationalizing equity values.

“We don’t want practitioners to walk away and think this is just another thing we have to do,” Thomas-Smith said. “Instead, we want to create a shared understanding that this is how we’re going to operate going forward. This isn’t just a training; it’s a movement.”

For more information, visit [www.apha.org/health-equity](http://www.apha.org/health-equity).

*APHA’s 2018 Annual Meeting and Expo will focus on “Creating the Healthiest Nation: Health Equity Now.” Registration is now open at [www.apha.org/annualmeeting](http://www.apha.org/annualmeeting).*

*   Copyright The Nation’s Health, American Public Health Association