Achieving Health Equity in the United States

  • Date: Nov 13 2018
  • Policy Number: 20189

Key Words: Health Equity, Health Disparities, Social Determinants of Health

Abstract
Decades of surveillance and research in the United States have documented health disparities in morbidity and mortality, particularly among racial/ethnic minority groups and those of lower socioeconomic status. Moreover, it is estimated that from 2003 to 2006 the combined costs of health inequities and premature deaths in the United States totaled $1.24 trillion and that elimination of health disparities among racial/ethnic minorities would have reduced these costs, including direct medical care, by $229.4 billion. In response to health inequities, national initiatives have been undertaken such as Healthy People 2020 and the National Partnership for Action to End Health Disparities. Despite Healthy People goals and objectives over several decades and modest reductions in health disparities in the United States, there are still persistent and pervasive disparities. Thus, more intentional, comprehensive, system-oriented, and coordinated strategies should be employed to achieve health equity in the United States. The action items presented in this policy statement call on national, state, and local governments, as well as nonprofit and philanthropic organizations and individuals, to implement policies, practices, surveillance, and research that include a health equity lens and framework across all sectors of society such that everyone can live a long life in optimal health.

Relationship to Existing APHA Policy Statements
The following are some relevant APHA policies that are more narrowly focused on individual social determinants of health and health disparities.

  • APHA Policy Statement 20179: Reducing Income Inequality to Advance Health
  • APHA Policy Statement 20178: Housing and Homelessness a Public Health Issue
  • APHA Policy Statement 201710: Protecting Children’s Environmental Health: A Comprehensive Framework
  • APHA Policy Statement 20173: Public Health and Early Childhood Education: Support for Universal Preschool in the United States
  • APHA Policy Statement 20101: Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities 
  • APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
  • APHA Policy Statement 20165: Addressing Social Determinants to Ensure On-Time Graduation
  • APHA Policy Statement 20167: Improving Health by Increasing the Minimum Wage
  • APHA Policy Statement 20091: Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities
  • APHA Policy Statement 20073: Environmental Injustices: Research and Action to Reduce Obesity Disparities
  • APHA Policy Statement 200311: Opposition to Eliminating or Compromising the Collection of Racial and Ethnic Data by State and Local Public Institutions
  • APHA Policy Statement 20017: Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health
  • APHA Policy Statement 20005: Effective Interventions for Reducing Racial and Ethnic Disparities in Health 
  • APHA Policy Statement 9612: Threats to Affirmative Action Are Threats to Health
  • APHA Policy Statement 8325: Access of Minority Medical Colleges to Public Hospitals
  • APHA Policy Statement 7424: Racism in the Health Care Delivery System
  • APHA Policy Statement 20062: Reducing Racial/Ethnic and Socioeconomic Disparities in Preterm and Low Birthweight Births

Problem Statement
A major public health problem in the United States is that a baby born today is expected to have a shorter life span and live in poorer health than a baby born in other high-income countries.[1] Likely explanations for babies in the United States experiencing a poorer quality of life and dying earlier are that, relative to other high-income, democratic countries, the United States lacks organized and coordinated health and social systems and does not invest as many of its resources in social services. These circumstances translate to limited access to primary care, a larger uninsured population, increases in certain health risk behaviors (drug abuse and firearm violence), a greater population in poverty, less quality education of children, and less investment in safety net social programs. Furthermore, an  outcome of these circumstances for U.S. babies during their life spans is that their health status varies by race/ethnicity; gender; income; education; cognitive, sensory, or physical disability; sexual orientation or gender identity; and place of residence (geography).[2–4]

There have been efforts at the community, state, and national levels to address these “unnatural” health differences by population and place across the United States. National initiatives have created measurable goals and objectives for the nation to monitor health outcomes and determinants of health. Healthy People, a science-based, 10-year health agenda, has measured national health promotion and disease prevention progress since 1979, and more recently is measuring not only health outcomes and risk behaviors but also the social determinants of health for the decade from 2010 to 2020.  Currently, plans are under way for measuring health outcomes and determinants for 2020 to 2030.[2–4] Eliminating health disparities and achieving health equity such that everyone has optimal health (well-being) remains a foundational principle that guides the development of Healthy People 2030.[4]  The purpose of Healthy People 2020 is to engage communities and every sector of society to act in improving health across the United States. The vision of Healthy People is that its goals and objectives in communities across the nation will be applied through engaging multiple sectors to take action as described in the National Academy of Medicine’s report Communities in Action: Pathways to Health Equity.[5] This report highlights the role of communities in driving action, policy, programs, or laws to promote health equity in communities. Partnerships between governments at every level and nongovernmental organizations (including not-for-profit organizations, foundations, and the private sector) are also envisioned through active participation of the entire nation working locally to implement effective policies and programs across all sectors in society.

The goals of Healthy People 2020 include achievement of health equity and creation of social and physical environments that promote good health for all.[2,3] Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people.”[2,6,7] Moreover, “[a]chieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”[4,8] Other definitions of health equity, for example the definition offered by Dr. Camara Jones (APHA past president), posit that health equity is the assurance that conditions for optimal health are available for all people, based on the premise that all people are valued equally and injustice is both recognized and rectified.[9]

To assess health equity, a major measure is elimination of health disparities.[1] Healthy People 2020 defines health disparities as “a particular type of health difference that is closely linked with social, economic, and environmental disadvantage.”[1] As such, health disparities are rooted in sociopolitical and economic history. Health disparities adversely affect populations that have systematically experienced greater obstacles to health based on their race or ethnicity, religion, socioeconomic status, gender, age, mental health, disability status, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.[3]

Despite Healthy People goals and objectives over several decades,[7] and although there have been some health improvements, there are still persistent and pervasive health disparities in the United States. For example, pervasive disparities were reported in the 2015 midcourse review of national health progress toward Healthy People targets.[10] Only modest reductions were found in health disparities among the widespread health and social objectives examined.[10] Of the up to 492 trackable objectives by race/ethnicity, the Healthy People target was met or exceeded for 36.9% of non-Hispanic Whites, 27.2% of non-Hispanic African Americans, 34.8% of Hispanics, 26.6% of American Indians/Alaska Natives, 47.8% of Asians, and 43.9% of Native Hawaiians or other Pacific Islanders.[10]

Examples of persistent health disparities include infant mortality, all-cause mortality, and life expectancy. In fact, U.S. life expectancy in all populations dropped from 78.9 years in 2014 to 78.7 years in 2015 and 78.6 years in 2016.[11] It is well known that infant mortality, all-cause mortality, and life expectancy differ by race/ethnicity, and these disparities have been documented over the past three decades. Trends in infant mortality from the 1980s to 2016 show disparities for African American infants relative to White infants; infant mortality among African American infants, on average, continues to be twice as high as mortality among White infants.[12,13] These disparities have worsened over time despite declines in overall U.S. infant mortality,[12] and more recent adverse trends have been found among Puerto Rican, American Indian/Alaska Native, and Pacific Islander infants.[2] Likewise, disparities persist in all-cause mortality and life expectancy at birth for African Americans relative to Whites, even though there have been overall improvements in both indicators of health.[12]  Furthermore, despite overall declines in cardiovascular disease (CVD) mortality, marked population and geographical inequities persist. A recent study showed a widening of the rural-urban disparity in CVD mortality, with mortality continuing to be higher in rural than urban communities.[14] From 1969 to 2011, the decline in CVD mortality was largest in New England and the Mid-Atlantic region and smallest in the Southeast and Southwestern regions. In 1969, the mortality differential in the Southeast relative to New England was 9%, and this differential increased to 48% in 2011.[14]

Other health outcomes such as obesity and diabetes, which have increased by epidemic proportions over the past few decades, show marked adverse disparities among African American and Hispanic populations in comparison with the White population at all time points during the 1980s to 2000s.[12] In addition, the legacy of slavery, racism, current oppression, and violence has impacted the mental health of African American populations. Several studies show that there is a relationship between self-reported experiences of racial discrimination and poor mental health among African Americans (as an example), including increased risk of depression, anxiety, substance use, and psychological distress.[15–17] Although the proportion of individuals receiving mental health treatment has increased, racial/ethnic disparities with respect to access to mental health treatment still persist among both children and adults.[18] In fact, this circumstance leads to members of racial/ethnic minority groups being less likely to achieve symptom remission and more likely to be chronically impaired after a diagnosis of a mental health disorder.[19]

Healthy People 2020 findings of persistent disparities in health outcomes and behavioral risk factors by socioeconomic status and education suggest that solutions to improve health outcomes for racial/ethnic and other disadvantaged populations point to upstream social determinants of health, including health care access, utilization, and quality.[20,21] These social and economic conditions, which are the “causes of the causes” of health disparities, vary not only by population characteristics but also by geography.[20] As such, inequities in certain social determinants of health are also assessed in Healthy People 2020 to understand what gives rise to disparities and to identify effective interventions so that all people are given the opportunity to realize the benefits of optimal health. Because of the U.S. political economy (the driver), which structures opportunities (advantages) and disadvantages for individuals, social determinants have been often described by race/ethnicity and income, which are measures of racism and classism, major drivers of social conditions.[3,7,22

Racism is defined as “institutional and individual practices that create and reinforce oppressive systems of race relations whereby people and institutions engaging in discrimination adversely restrict, by judgement and action, the lives of those against whom they discriminate.”[23] Racism is a major social determinant of health disparities. According to Jones, racism occurs on three levels: institutional, personally mediated, and internalized. Institutional racism is defined as “differential access to goods, services and opportunities of society by race.”[24] Personally mediated racism is defined as “prejudice and discrimination where prejudice means differential assumptions about the abilities, motives and intentions of others by race and discrimination is the differential actions toward others according to their race.” An unfortunate consequence of these two forms of racism is internalized racism, which is the “acceptance by members of stigmatized races of negative messages about their own abilities and intrinsic worth.”[24] APHA has recently begun a campaign against racism initiated by Jones.

Disparities in poor health outcomes described by racial/ethnic populations (of which racism is a contributor) place a substantial health burden on the nation and its workforce and give rise to an extreme economic burden.[25] This economic burden, which concerns communities of color but also can spark concern throughout the entire nation, has been quantified and calculated.[26] It is estimated that between 2003 and 2006, eliminating health disparities among racial/ethnic minority populations would have reduced direct medical care expenditures by $230 billion and indirect costs to society (due to loss of productivity from illness and premature death) by more than $1 trillion.[26] This evidence illustrates the cost effectiveness of eliminating racial/ethnic health disparities.

Along with the important health, social, and economic burdens to society based on the existence of health inequities, government and private sectors have a number of legal obligations related to racial equity, disability accessibility, and avoidance of gender-based discrimination. In addition, there is a growing body of legislation designed to prohibit discrimination based on sexual orientation or gender identity.[1] Examples of legal obligations and extent of implementation are described below for housing and education.

Housing: To build healthy communities as outlined in the National Prevention Strategy, all people must have access to safe, affordable, and stable housing. Access to housing has a direct and tangible impact on people’s ability to access quality education as well as on other social determinants of health. Specifically, housing segregation has a direct connection with student poverty rates and inadequate school resources, among other indicators of poor academic outcomes.[27] The federal government passed the Civil Rights Act of 1968 to specifically respond to various ways that American life had been divided based on race. Title VIII of the Civil Rights Act, known as the Fair Housing Act, prohibits race-based discrimination in housing with the express goal of “replacing ghettos” and creating truly integrated neighborhoods.

More recently, potential renters have come up against a new iteration of housing discrimination in the form of online ads. Yet, section 3604(c) of the Fair Housing Act specifically targets media postings (e.g., Craigslist) and prohibits racial discrimination using media platforms. Even with these clear legal obligations prohibiting racial discrimination in renting and home buying, housing segregation persists. Moreover, this systematic grouping of resource-rich and resource-poor neighborhoods[28] has a ripple effect on the ability of certain communities to access stable housing and, in turn, on their access to quality services.

Education: Access to education is a crucial social determinant of health.[29] It has been shown that “[p]eople with less education have higher rates of illness, higher rates of disability, and shorter life expectancies.”[30] However, in the United States, even decades after the landmark civil rights decision by the U.S. Supreme Court in Brown v. Board of Education, education is largely segregated on the basis of race and socioeconomic status.[31] Furthermore, there is no federal or constitutional right to education, and communities must rely primarily on state constitutions and special education laws to ensure equitable access to educational opportunities. K–12 education access is tightly interwoven with access to housing, as in most places students are assigned to schools based on their residence and school districts are divided along the same racial and socioeconomic lines as housing. The Supreme Court has unfortunately held that interdistrict integration is an inappropriate remedy where there has been no finding that wealthier (usually suburban) districts directly contributed to the harm suffered in less affluent districts (Milliken v. Bradley, 1974). In addition to the harm caused by racially segregated school districts, students’ access to quality education is hampered by exclusionary discipline policies that unfairly remove students of color, students with disabilities, and LGBTQ (lesbian, gay, bisexual, transgender, and queer) and non-gender-conforming (GNC) students from the classroom.[32] However, students do have some protections through the Individuals with Disabilities in Education Act, a federal law requiring that students with disabilities receive a free appropriate public education and that parents have a private right of action to demand that their child’s school district develop an educational plan that will allow the student to make meaningful educational progress.

To ensure equitable access to public education, cities and states across the country must commit to redistributing school funding in ways that are equitable and that undo the past and present harm caused by racial housing segregation. Furthermore, communities and districts must commit to eliminating “zero-tolerance policies,” which have been shown to disproportionately exclude youths of color, youths with disabilities, and LGBTQ and GNC students. The American Academy of Pediatrics has released a policy statement detailing that students who have been suspended or expelled are more likely to drop out of high school and calling for a reduction in zero-tolerance policies and an increase of prevention efforts, including early intervention for preschool students and positive behavioral support and interventions within schools.[32] In addition, the American Bar Association’s Joint Task Force on Reversing the School-to-Prison Pipeline called for the removal of zero-tolerance policies from schools and for legislation designed to eliminate criminalization of students for behavior that does not harm others.[33]

Summary: Unfulfilled legal obligations and persistent and pervasive health inequities are major public health problems because inequities cause tremendous health, economic, and ethical burdens for U.S. society, and there is a need for enforcement of legal protections from discrimination. Elimination of health disparities is cost effective, and if nothing is done these societal burdens are projected to worsen as the U.S. population becomes more diverse and multicultural. By 2044, the United States is projected to become a majority-minority country.[34] Furthermore, racial/ethnic minority and low-income populations combined now represent nearly one half of the U.S. population.[34,35]

Evidence-Based Strategies to Address the Problem
While there is not a comprehensive, coordinated strategy for the nation to achieve health equity, there are science- and evidence-based national strategies and initiatives that have demonstrated success in reducing or eliminating some health disparities at the local level and in communities because they have effectively addressed the social determinants of health, including racism and classism. Many are discussed in an Institute of Medicine report titled How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary.[36] Although national initiatives are emphasized as key opportunities, it is realized that their success involves multisector partnerships at every level of government and with nongovernmental, nonprofit organizations. These initiatives are discussed in the context of the Patient Protection and Affordable Care Act and include but are not limited to the following:  the dual vaccination strategy, the recommendations of the Community Preventive Services Task Force (CPSTF), Healthy People 2020 goals and objectives, the National Prevention Strategy (NPS),  the National Partnership for Action to End Health Disparities (NPA), the Environmental Justice Strategy and Implementation Plan, the Public Health Accreditation Board standards for public health agencies,  the Culture of Health initiative of the Robert Wood Johnson Foundation, Association of State and Territorial Health Officials (ASTHO) and National Association of County and City Health Officials (NACCHO) programs and initiatives to achieve health equity, and APHA efforts to achieve the healthiest nation in a generation.

The dual vaccination strategy includes multicomponent, evidence-based interventions designed to reach the general population of children in U.S. communities and targeted interventions designed to reach the most vulnerable children (e.g., those from underserved, low-income, and racial/ethnic minority populations) and high-risk communities (those at risk of vaccine-preventable illnesses because of low vaccination coverage).[37,38] Universal interventions include regular assessments of vaccination services for children at the local, state, and national levels and in health care practices.[37,38] At the health care practice level, the focus is on provision of high-quality vaccination services through practice standards, standing orders, and assessment of services.[39] Targeted interventions, based on the needs of the most vulnerable children, have enabled low-income and racial/ethnic minority children and high-risk communities to gain routine access to health care services via the Vaccines for Children Program. In addition, there is increased awareness of the need for and availability of vaccination services through strategic partnerships between public health agencies and community organizations at all levels of governmental public health, particularly faith-based organizations.[37,38] The Vaccines for Children program specifically provides free vaccines to uninsured and underinsured children.[40]

The evidence-based recommendations of the CPSTF represent examples of interventions proven to improve the quality of health care service delivery. Evidence-based recommendations also exist for communities in reducing risk behaviors for chronic diseases and injuries.[39] These recommendations, when applied to communities, have been proven to improve health.[39]

As mentioned, Healthy People 2020 provides achievable and measurable objectives for improving the health of all that are applicable at the national, state, and local levels.[2,3] Regular and routine monitoring of objectives requires assessments of the overall population at these levels as well as assessments of different groups by education, race/ethnicity, income, disability, and geographic location.[3] This strategy of monitoring the health objectives of individuals in communities, counties, states, and the nation reflects the adage “what gets measured, gets done.”[41]

The NPS, a key national initiative that includes targeted interventions as components, is designed to improve the resilience of all populations by addressing the social determinants of health.[42] The NPS goal is to increase the number of Americans who are healthy at every stage of life.[42] This goal is accomplished via four strategic directions: eliminating health disparities, building healthy and safe communities (e.g., through provision of clean air and water and affordable housing), integrating community and clinical preventive services and enhancing the quality of both, and empowering people to make healthy choices. Elimination of health disparities is applied across the other three directions and nine priority areas to reduce the burden of the leading causes of preventable deaths and major illnesses in the United States.[42] An example of integration of community and clinical preventive services is enabling access to clinical services by providing transportation, child care, and patient navigation interventions.[42] The nine priorities, which include tobacco-free living, prevention of drug abuse and excessive alcohol use, healthy eating, active living, and mental and emotional well-being, can reduce poor health outcomes.[42] Full implementation of the NPS in all communities, including those with substantial racial/ethnic minority and low-income populations, should improve community health.

While education and housing are important social determinants of health, racism (as mentioned) plays a dynamic role in shaping the health and well-being of individuals and populations alike. Throughout the nation, there are a number of efforts taking place at the state and local levels, particularly around building capacity to address racism. Training, webinars, and coalitions and committees formed by national and local organizations provide health departments, hospitals, businesses, and communities with tools and resources to recognize, address, and eliminate racism. Anti-racism training sessions, such as those taught by the Racial Equity Institute, the Center for Racial Justice Innovation, Clear Impact, and the Race Matters Institute, focus on creating racial equity and challenging the status quo.[43–46] These training sessions equip communities and the workforce with knowledge, skills, and resources regarding racial equity. Webinars such as those sponsored by APHA,[47] the Latino Medical Student Association,[48] and Human Impact Partners[49] offer an opportunity to examine the structural barriers that preserve racism while advancing racial and health equity. Coalitions and committees such as Organizing Against Racism, the Interfaith Coalition Against Racism, the United Nations Human Rights Committee on the Elimination of Racial Discrimination, and the International Justice Resource Center’s Committee on the Elimination of Racial Discrimination focus on disassembling racism while promoting justice.[50–53] In addition, organizations such as the National Collaborative for Health Equity, CommonHealth ACTION, the Aspen Institute, the W.K. Kellogg Foundation, and the Center for Ethical Leadership provide funding and resources to organizations in an effort to address the impact of racism.[54–56]

Interventions and initiatives targeting upstream social determinants of health are likely most effective in improving health equity. The NPA, a targeted umbrella initiative led by the Office of Minority Health of the U.S. Department of Health and Human Services (DHHS), is expected to mobilize a nationwide, comprehensive, community-driven, and sustained approach for combating health disparities and for moving the nation toward achieving health equity.[8] Systems-oriented, cross-sector, partnership-based, and community-driven approaches to eliminating health disparities include a national stakeholder strategy for achieving health equity. The goals of this strategy are to increase awareness of the impact of health disparities and actions needed for improving health among racial, ethnic, and underserved populations; to strengthen leadership in addressing health disparities; to improve health and health care outcomes for racial, ethnic, and underserved populations; to improve cultural and linguistic competency and the diversity of the health workforce; and to improve data, research, and diffusion of research and evaluation outcomes.[57] To accomplish the stakeholder plan, there are regional health councils in place. All public health agencies and the private sector could benefit from the guidance of the NPA regional health equity councils and state minority health directors, and they should engage in efforts with community health workers to educate and empower communities and individuals.[58,59] These councils and directors have established trusted partnerships in underserved and minority communities, and they can assist public health agencies in developing community improvement plans.

An example of such endeavors can be seen in the work accomplished by the National Indian Health Board and the National Partnership for Action. To build capacity and improve outcomes for tribal communities, these two organizations have collaborated in a joint effort sponsored by the Office of Minority Health.[60] This effort has provided resources to tribal public health departments surrounding public health accreditation and bolstered “use of the social determinants of health and health equity frameworks in programming and in community health needs assessments.

The 2012 DHHS Environmental Justice Strategy and Implementation Plan delineates actions to address environmental health disparities experienced by minority and low-income populations and American Indian tribes.[36] Environmental justice is defined as fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income in the development, implementation, and enforcement of environmental laws, regulations, and policies.[61] This definition was developed in response to a body of science and community advocacy indicating a disproportionate burden of environmental pollution among minority, low-income, and tribal populations in the United States.[61] The Environmental Justice Strategy and Implementation Plan builds on an earlier strategy from 1995 to protect the health and advance the economic potential of communities overburdened by pollution and other environmental hazards.[61] The four interrelated parts of the 2012 strategy are linked to climate change polices and directives such as policy development and dissemination; education and training; research and data collection, analysis, and utilization; and services.[61] The plan provides a roadmap for DHHS agencies to develop their own environmental justice strategies and plans, to enhance accountability, and to promote collaboration and meaningful community partnerships.

To strengthen the public health infrastructure and improve routine public health agency performance, the Public Health Accreditation Board offers an accreditation process for state, local, tribal, and territorial public health agencies.[62] As of August 2016, 150 local, tribal, and state agencies and one integrated state system of 67 local agencies were accredited.[62] An accredited public health agency meets national standards based on the 10 essential public health services. The accreditation standards drive public health agencies to develop and use documents such as community-driven health improvement plans, agency strategic plans, and emergency operations plans. With accreditation standards, there is strong attention to understanding emerging trends, using assessment data and identifying jurisdiction-specific needs and issues, and addressing health equity, cultural competency, and vulnerable populations. As such, the accreditation process and national standards are driving attention to important topics and actions, which could strengthen the preparedness and response of communities to the health impacts of climate change and improve efforts to address threats faced by vulnerable populations by more strongly motivating public health agencies to take actions required to address their needs. In addition to meeting overall standards, accredited agencies meet specific cultural competency standards.[62]

As mentioned in the problem statement, the health status of individuals in the United States is poor relative to those living in other high-income countries, and life expectancy is shorter. A major explanation for shorter life expectancy is that countries with the best health outcomes provide the strongest social services for their populations.[1] There is a need for social supports to improve health status and reduce health inequities in the United States.

The APHA goal is for the United States to become the healthiest nation in a generation by 2030. To accomplish this goal, APHA calls for the conduct of eight science-based key actions[63]:

  • Build safe, healthy communities
  • Help all young children graduate from high school
  • Reverse growing income inequalities
  • Remove barriers to good health for everyone
  • Provide affordable, nutritious food for everyone
  • Effectively prepare for and respond to the health impacts of climate change
  • Provide quality health care to everyone
  • Strengthen public health infrastructure

Furthermore, considerable literature exists denoting additional specific strategies in smaller localities that have led to improvements in health equity through addressing the social determinants of health. These strategies include, but are not limited to, research strategies (such as community-based participatory research), housing program and policy strategies (such as tenant-based rental assistance programs), and educational program and policy strategies (such as center-based early childhood education, full-day kindergarten programs, and high school completion programs).[64]

Also, critical state and local strategies to improve health equity are being led by nonprofit organizations. APHA has implemented case studies, as have NACCHO, ASTHO, and the Robert Wood Johnson Foundation.[9,65–67] In addition, a community of practice in North Carolina, which has the shortest life expectancies in the nation, has developed a health equity framework.[68,69] North Carolina has its own Office of Minority Health and Health Disparities, which generates health equity reports evaluating the state’s progress in eliminating health disparities.[68] The Chronic Disease and Injury Section of the North Carolina Department of Health and Human Services strives to decrease death and disability by way of education, policy change, and health services.[69] Within that section are communities of practice that aim to further the section’s work.[69] One community of practice developed a health equity framework that encompasses priorities, key activities, and terminologies surrounding health disparities, health inequities, and the social determinants of health. This framework offers an approach to advancing health equity while providing strategies and a common language that can be used to inform the policies of decision makers and increase funding for health equity in grant applications.[68,69]

In prioritizing multisectoral approaches to achieving health equity, the “health in all policies” approach provides an opportunity for multifaceted collaboration focusing on the social determinants of health.[70] This upstream approach also promotes the importance of considering health in developing every decision and throughout a wide range of sectors.[70] ASTHO asserts that “by taking a broader view of what creates health, we can better understand how policies related to transportation, housing, education, public safety or environmental protection can affect health outcomes.”[71]

Building safe communities also requires aggressive enforcement of existing civil rights protections and active work to undo the past harms caused by redlining, predatory lending, and other forms of discrimination in housing. Continued research and aggressive policy changes to hold financial institutions, landlords, and other actors accountable for fighting racial inequity in housing are absolutely necessary to combat inequity in housing.

In the journey toward achieving health equity in the United States, effective interventions to address the social determinants of health continue to be needed at the nonprofit and philanthropic organizational- levels.[5] It is estimated that 45% to 57% of the drivers of health determinants are outside of health care, supporting the need for intentional, collaborative, coordinated, and innovative efforts to address the social determinants of health.[72] Nongovernmental organizations play a critical role in stimulation of innovation; for example, the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation work through programs and grants to engage communities, policymakers, business leaders, and other stakeholders to set a standard for health equity in communities and to provide evidence for the business case for racial equity.[67,73] In addition, there are numerous other foundations that impact health, are thought leaders, and provide funding to impact decisions, policies, and programs that can address health equity, including the Henry J. Kaiser Family Foundation, Kaiser Permanente, the Ford Foundation, the California Healthcare Foundation, the Commonwealth Fund, and the California Endowment.

The Institute of Medicine’s report Communities in Action: Pathways to Health Equity further supports the notion that health is shaped by community context and is the product of multiple determinants.[5] This report provides examples of innovative evidence-based strategies and recommendations for closing equity gaps. In addition, the report acknowledges that both governmental and community actors are necessary but are independent of one another and are not sufficient for the advancement of equity. The community-driven initiatives included in the report illustrate several promising cross-cutting elements that promote equity, including creating a shared vision and building trust in the community, developing leadership, and building diverse partners through relationship building and mutual accountability.[5] By developing strategic partnerships/collaborations and building community capacity for equity, communities can successfully impact socioeconomic and political frameworks accounting for a range of factors such as employment, public safety, housing, transportation, and education.[5] It is evident through these examples that community-based organizations and subsequent partnerships are drivers of change and are a fundamental component in the implementation of effective strategies in pursuit of health equity. To further strengthen the success of this work, communities need evidence (from research), tools, supportive policies, resources, and political will that will nurture local efforts.[5]

Opposing Arguments/Evidence
There are fundamental opposing arguments used against attaining health equity that are underlying values of decision makers and policymakers (e.g., capitalism, xenophobia, and sexism). These opposing arguments are as follows: (1) personal health choices are the responsibility of the individual and (2) the scarcity of resources leads to a need for a balance between health rationing and what is acceptable as redistribution of resources.[74]

Credence given to these fundamental opposing arguments, however, is difficult because during the public meetings for Healthy People 2010, when elimination of health disparities became a national health goal, the public expressed concern that differences in health status by race/ethnicity and income were unacceptable.[75] In addition, as previously mentioned, the cost effectiveness of eliminating health inequities[26] and the business case for racial equity[73,76] are strong economic arguments in support of achieving health equity.

Moral and ethical arguments have also been used to refute other opposing arguments. For example, Dr. Cynthia Jones has offered ethical arguments refuting specific prevailing opposing arguments against the elimination of health disparities.[77] She describes the following three prevailing opposing arguments to elimination of disparities: “The first opposing argument is that it is not necessarily wrong that some people are ‘less healthy’ than others. The second opposing argument holds that different cultural groups may exhibit cultural habits that perpetuate health disparities and the third opposing argument is that addressing health disparities is a waste of resources, as substantial resources have already been spent studying the problem of health disparities, yet the disparities persist.”[77] Jones then refutes these opposing arguments as follows.

  • Refuting the first opposing argument: Even if individuals are responsible for their own health and, more important, the health disparities with which we are concerned are disparities that follow racial/ethnic lines and socioeconomic distinctions, it would be a strange leap to suppose that the members of a particular ethnic population are responsible for their lower health outcomes or that the poor are responsible for their lack of access to adequate medical care. Even if we assume, for the sake of argument, that this is indeed the case, we may still argue that the high rate of diabetes and heart disease in minority populations, for example, is a problem that should be addressed through education, even if the population as a whole exhibits habits that are unhealthy and are somewhat within their control. Public health programs designed to educate the public about the dangers of smoking are an example of this logic at work.[77] Furthermore, individuals’ choices are strongly influenced by options and opportunities in their environments, and in some communities, geographic areas, and socioeconomic groups individuals are limited by their access to making healthy choices.
  • Refuting the second opposing argument: Cultural practices that result in significant health risks should be addressed, albeit as sensitively as possible. If a cultural practice results in harm to the individual or to others, then it would be morally problematic to ignore such harm. It may be that we can educate individuals about potential harm while presenting healthier alternatives that are not antithetical to a group’s ethnic and cultural practices.[77]
  • Refuting the third opposing argument: We should not abandon efforts to address a problem because past efforts have been unsuccessful. Efforts to address diseases such as Alzheimer’s disease and breast cancer and social problems such as domestic violence and poverty should not be curtailed because these diseases and problems persist. There is also no clear evidence that the problem is indeed “unfixable.” At best, this objection points to the need to rethink approaches to addressing health disparities. Numerous factors, such as health literacy, housing, environmental toxins, mistrust of health care professionals, and lack of insurance, affect health and can perpetuate or increase health disparities. Clearly, a complex tangle of factors is at work to affect health and contribute to significant health disparities in the United States. We need to develop creative, broad-based approaches to address these inequities. Rather than pulling health disparities out of the social context in which they are entrenched and attempting to address them narrowly, researchers should find ways to address health disparities within the social context, which may require “fixing” more than just the health disparities. Perhaps increasing public awareness of health disparities as a moral issue can contribute to addressing this problem.[77]

Action Steps
The action steps outlined below are based on the science- and evidence-based strategies described previously and are structured at the national, state, local, and nongovernmental levels, with ultimate impacts at the individual and community levels. It is recognized that nongovernmental partners also play a major role in fostering healthy communities.

National Level

  • Congress should fund fully, and the federal government should implement fully, the Affordable Care Act, including (1) providing access to health services for everyone (through health insurance and promotion of Medicaid expansion by states on the path to universal access to health care), (2) implementing the recommendations of the U.S. Preventive Services Task Force and the CPSTF, (3) collecting required data, and (4) implementing value-based health care.
  • Congress should fund fully the National Prevention Strategy and Implementation Plan and the National Partnership for Action to End Health Disparities, including implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
  • Congress should continue to fund research on elimination of health inequities through the National Institute on Minority Health and Health Disparities as well as other institutes at the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), the Substance Abuse and Mental Health Services Administration, and the Patient-Centered Outcomes Research Institute (PCORI).
  • The CDC, ASTHO, NAACHO, the Robert Wood Johnson Foundation, and other organizations should develop and implement evidence-based toolkits for communities to implement interventions that include the dual strategy approach of universal interventions and targeted interventions to reach society’s most vulnerable populations
  • Congress should fund and implement fully social safety net services such as quality education, housing, jobs, and transportation.
  • Congress should permanently reauthorize special provisions of the 1965 Voting Rights Act to prevent further reauthorizations.
  • Federal, state, and local governments should enforce civil rights laws to achieve health equity.
  • The CDC should continue to monitor progress on eliminating health disparities and health inequities and consider new methods to expand monitoring of health outcomes by socioeconomic status in addition to race/ethnicity.
  • The CDC, NIH, AHRQ, and PCORI should continue and expand community research to identify models to reduce health disparities in communities across the United States.
  • The CDC and the W.K. Kellogg Foundation should engage in efforts to reduce breastfeeding disparities across the United States.[78]

State/Local Level

  • State governments should expand Medicaid to improve universal access to health care.
  • State and local public health agencies should create broad coalitions with regional and state health equity councils and minority health directors to reach the most vulnerable populations (racial/ethnic minority and low-income populations) through health in all policies initiatives and other evidenced-based efforts to improve population health.
  • State and local governments should fund state and local public health agency accreditation efforts.
  • State and local governments should implement evidence-based interventions and identify practice-based interventions found to eliminate health disparities (e.g., communities of practice).
  • State and local governments should support social policies to improve education, income, housing, jobs, and transportation.
  • State and local governments should work with urban planners and health professionals to foster incorporation of health in planning, policy, and decision-making frameworks to create healthy communities.
  • >State and local public health agencies should include the most vulnerable populations in developing, implementing, and evaluating community improvement plans and training.
  • State and local governments should implement a dual strategy approach of public health programs and prevention programs.

Nongovernmental Organizations

  • Nongovernmental organizations such as the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation should continue to introduce paradigm shifts such as the Culture of Health initiative and the business case for racial equity.
  • Nongovernmental organizations should work with partners to create healthy communities.
  • Nongovernmental organizations such as the Kellogg Foundation, the Satcher Institute, and the American Medical Students Association should enhance scholarship and fellowship programs seeking to develop public health leaders in academia and health policy who are focused on eliminating health disparities and advancing health equity.
  • Academic institutions, in the major role of identifying effective interventions in communities to achieve health equity, should focus research particularly on the discovery of interventions that intervene on the social determinants of health in communities across the United States.
  • Academic institutions should focus on training members of the public health workforce with the specific knowledge and skills they need to prepare them for leadership roles in developing, promoting, and implementing research and policies to advance health equity. Moreover, these institutions should enhance and develop centers and curriculums focused on advancing health equity, specifically providing graduates with the necessary training to work effectively with disadvantaged communities to develop sustainable programs and critically analyze issues, programs, and policies that impact health disparities and advance health equity.

Individuals/Communities

  • Individuals and communities should advocate for political, social, and economic policies and programs that will improve health for the most vulnerable populations, families, and communities, as well as policies that support health advancement of multicultural populations.
  • Individuals and communities should understand their legal rights and obligations to uphold civil rights laws and disability laws and advocate for enforcement of such laws.

Cross Cutting

  • Federal, state, and local governments; professional organizations; and businesses should create a pipeline of public health and preventive medicine physicians and professionals made up of members of the most vulnerable populations in U.S. society.
  • Federal, state, and local governments should adopt a “health in all polices approach” to ensure that health issues are addressed broadly, especially with respect to social policies that affect vulnerable populations.

References
1. National Research Council. The National Academies Collection: Reports Funded by the National Institutes of Health. In: Woolf SH, Aron L, eds. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press; 2013.
2. Healthy People 2020. Available at: https://www.healthypeople.gov/2020/About-Healthy-People. Accessed January 18, 2019.
3. Fielding JE, Kumanyika S, Manderscheid RW. A perspective on the development of the Healthy People 2020 framework for improving U.S. population health. Public Health Rev. 2013;35:3.
4. Healthy People 2030 framework. Available at: https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework 2018. Accessed January 18, 2019.
5. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2017.
6. U.S. Department of Health and Human Services. Office of Minority Health home page. Available at: http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?&lvl=2&lvlid=34. Accessed January 18, 2019.
7. Braveman PA, Kumanyika S, Fielding J, et al. Health disparities and health equity: the issue is justice. Am J Public Health. 2011;101:S149–S155.
8. U.S. Department of Health and Human Services. National Partnership for Action to End Health Disparities. Available at: https://minorityhealth.hhs.gov/npa/. Accessed January 18, 2019.
9. National Association of County and City Health Officials. Cultivating a Culture of Health Equity. Available at: https://nacchovoice.naccho.org/2016/07/28/naccho-annual-2016-cultivating-a-culture-of-health-equity/. Accessed January 18, 2019.
10. Healthy People 2020 midcourse review. Available at: https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B03-Overview.pdf. Accessed January 18, 2019.
11. Kochanek KD, Murphy S, Xu J, Arias E. Mortality in the United States, 2016. NCHS Data Brief. 2017;293:1–8.
12. Bleich SN, Jarlenski MP, Bell CN, LaVeist TA. Health inequalities: trends, progress, and policy. Annu Rev Public Health. 2012;33:7–40.
13. Rossen LM, Schoendorf KC. Trends in racial and ethnic disparities in infant mortality rates in the United States, 1989–2006. Am J Public Health. 2014;104:1549–1556.
14. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969–2009. J Urban Health. 2014;91:272–292.
15. Banks KH, Kohn-Wood LP, Spencer M. An examination of the African American experience of everyday discrimination and symptoms of psychological distress. Community Ment Health J. 2006;42:555–570.
16. Chae DH, Lincoln KD, Jackson JS. Discrimination, attribution, and racial group identification: implications for psychological distress among Black Americans in the National Survey of American Life (2001–2003). Am J Orthopsychiatry. 2011;81:498–506.
17. Pittman CT. Getting mad but ending up sad: the mental health consequences for African Americans using anger to cope with racism. J Black Stud. 2011;42:1106–1124.
18. Le Cook B, Barry CL, Busch SH. Racial/ethnic disparity trends in children’s mental health care access and expenditures from 2002 to 2007. Health Serv Res. 2013;48:129–149.
19. Eack SM, Newhill CE. Racial disparities in mental health outcomes after psychiatric hospital discharge among individuals with severe mental illness. Soc Work Res. 2012;36:41–52.
20. Koh HK, Piotrowski JJ, Kumanyika S, Fielding JE. Healthy People: a 2020 vision for the social determinants approach. Health Educ Behav. 2011;38:551–557.
21. Vega WA, Sribney WM. Growing economic inequality sustains health disparities. Am J Public Health. 2017;107:1606–1607.
22. Jones C. Confronting institutionalized racism. Phylon. 2002;50:7–22.
23. Krieger N. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: an ecosocial perspective. Am J Public Health. 2003;93:194–199.
24. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90:1212–1215.
25. McCullough JC, Zimmerman FJ, Fielding JE, Teutsch SM. A health dividend for America. Am J Prev Med. 2012;43:650–654.
26. LaVeist TA, Gaskin D, Richard P. Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv. 2011;41:231–238.
27. Seicshnaydre SE. The fair housing choice myth. Cardozo Law Rev. 2012;33:967–1018.
28. Woolf SH, Zimmerman E, Haley A, Krist AH. Authentic engagement of patients and communities can transform research, practice, and policy. Health Aff (Millwood). 2016;35:590–594.
29. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100:590–595.
30. Robert Wood Johnson Foundation. Education: it matters more to health than ever before. Available at: https://www.rwjf.org/en/library/research/2014/01/education--it-matters-more-to-health-than-ever-before.html. Accessed January 18, 2019.
31. Rothstein R. For public schools, segregation then, segregation since. Available at: https://www.epi.org/publication/unfinished-march-public-school-segregation/. Accessed January 18, 2019. 
32. American Academy of Pediatrics Committee on School Health. Out-of-school suspension and expulsion. Pediatrics. 2003;112:1206–1209.
33. Redfield S, Nance J. Joint Taskforce on Reversing the School-to-Prison Pipeline. Available at: https://www.americanbar.org/content/dam/aba/publications/criminaljustice/school_to_prison_pipeline_report.authcheckdam.pdf. Accessed January 18, 2019.
34. U.S. Census Bureau. Annual estimates of the resident population by sex, race, and Hispanic origin for the United States, states, and counties. Available at: http://factfinder2.census.gov/bkmk/table/1.0/en/PEP/2013/PEPSR6H. Accessed January 18, 2019.
35. DeNavas-Walt CP. Income and Poverty in the United States: 2013. Washington, DC: U.S. Census Bureau;2013.
36. Institute of Medicine. How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary. Washington, DC: National Academies Press; 2012.
37. Hutchins SS, Bernier R. Elimination of measles and of disparities in measles childhood vaccine coverage among racial and ethnic minority populations in the United States. J Infect Dis. 2003;189:S146–S152.
38. Williams WW, Orenstein WA, Rodewald L. Immunization and preventive care. In: Satcher D, ed. Multicultural Medicine and Health Disparities. New York, NY: McGraw-Hill; 2006:233–249.
39. Community Preventive Services Task Force. The Community Guide. Available at: https://www.thecommunityguide.org. Accessed January 18, 2019.
40. Centers for Disease Control and Prevention. Vaccines for Children Program. Available at: https://www.cdc.gov/vaccines/programs/vfc/index.html. Accessed January 18, 2019.
41. Community Preventive Services Task Force. Vaccination programs: provider assessment and feedback. Available at: https://www.thecommunityguide.org/findings/vaccination-programs-provider-assessment-and-feedback. Accessed January 18, 2019.
42. Centers for Disease Control and Prevention. National Prevention Strategy. Available at: http://www.cdc.gov/features/annual-status-report/index.html. Accessed January 18, 2019.
43. Racial Equity Institute. REI home page. Available at: https://www.racialequityinstitute.com/. Accessed January 18, 2019.
44. Center for Racial Justice Innovation. Racial justice training. Available at: https://www.raceforward.org/trainings. Accessed January 18, 2019.
45. Clear Impact. Racial equity workshop. Available at: https://clearimpact.com/our-events/racial-equity-workshop/. Accessed January 18, 2019.
46. Race Matters Institute. What we do. Available at: http://viablefuturescenter.org/racemattersinstitute/. Accessed January 18, 2019.
47. American Public Health Association. Naming and addressing racism: a primer. Available at: https://www.apha.org/events-and-meetings/apha-calendar/webinar-events/naming-and-addressing-racism. Accessed January 18, 2019.
48. LMSA National. Addressing racism in medicine. Available at: https://twitter.com/LMSA_National/status/970086468256501760. Accessed January 18, 2019.
49. Human Impact Partners. Health equity guide. Available at: https://humanimpact.org/hipprojects/hegwebinars2017/. Accessed January 18, 2019.
50. Organizing Against Racism. Who we are. Available at: https://www.oaralliance.org/. Accessed January 18, 2019.
51. Interfaith Coalition Against Racism. Resources. Available at: http://chicagoicar.org/. Accessed January 18, 2019.
52. Office of the United Nations High Commissioner for Humans Rights. Committee on the Elimination of Racial Discrimination home page. Available at: https://www.ohchr.org/en/hrbodies/cerd/pages/cerdindex.aspx. Accessed January 18, 2019.
53. Internation Justice Resource Center. Committee on the Elimination of Racial Discrimination. Available at: https://ijrcenter.org/un-treaty-bodies/committee-on-the-elimination-of-racial-discrimination/. Accessed January 18, 2019.
54. National Collaborative for Health Equity. Community strategies to end racism and support racial healing: the Place Matters approach to promoting racial equity. Available at: http://www.nationalcollaborative.org/wp-content/uploads/2016/02/Community-Strategies-to-End-Racism-and-Support-Racial-Healing-The-Place-Matters-Approach-to-Promoting-Racial-Equity-.pdf 2015. Accessed January 18, 2019.
55. Aspen Institute. Structural racism and community building. Available at: http://www.racialequitytools.org/resourcefiles/aspeninst3.pdf. Accessed January 18, 2019.
56. Leadership Learning Community. Developing a racial justice and leadership framework to promote racial equity, address structural racism, and heal racial and ethnic divisions in communities. Available at: http://leadershiplearning.org/system/files/Racial%20Equity%20and%20Leadership%20Scan.pdf. Accessed January 18, 2019.
57. U.S. Department of Health and Human Services. National Stakeholder Strategy for Achieving Health Equity. Available at: https://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286. Accessed 10 April 2017. Accessed January 18, 2019.
58. U.S. Department of Health and Human Services. Regional health equity councils. Available at: https://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=42. Accessed January 18, 2019.
59. Office of Minority Health. State minority health contacts. Available at: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=6. Accessed January 18, 2019.
60. Espinosa O, Coffee-Borden B, Bakos A, Nweke O. Implementation of the National Partnership for Action to End Health Disparities: a three-year retrospective. J Health Disparities Res Pract. 2016;9:6.
61. U.S. Department of Health and Human Services. 2012 Environmental Justice Strategy and Implementation Plan. Available at: http://www.hhs.gov/sites/default/files/environmentaljustice/strategy.pdf. Accessed January 18, 2019.
62. Public Health Accreditation Board. Accredited health departments. Available at: http://www.phaboard.org/news-room/accredited-health-departments/. Accessed January 18, 2019.
63. American Public Health Association. National Public Health Week 2016. Available at: http://www.publichealthnewswire.org/?p=14627. Accessed January 18, 2019.
64. Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health. 2010;100:S40–S46.
65. American Public Health Association. Health equity. Available at: https://www.apha.org/topics-and-issues/health-equity. Accessed January 18, 2019.
66. Association of State and Territorial Health Officials. Programs. Available at: http://www.astho.org/Programs/Health-Equity/. Accessed January 18, 2019.
67. Robert Wood Johnson Foundation. Building a culture of health. Available at: https://www.rwjf.org/en/how-we-work/building-a-culture-of-health.html. Accessed January 18, 2019.
68. North Carolina Office of Minority Health and Health Disparities. Health equity report. Available at: http://www.ncminorityhealth.org. Accessed January 18, 2019.
69. North Carolina Department of Health and Human Services. Chronic Disease and Injury Section. Available at: https://publichealth.nc.gov/chronicdiseaseandinjury/. Accessed January 18, 2019.
70. American Public Health Association. Health in all policies. Available at: https://www.apha.org/topics-and-issues/health-in-all-policies. Accessed January 18, 2019.
71. Association of State and Territorial Health Officials. Implementing a “health in all policies” approach with health equity as the goal. Available at: http://www.astho.org/Health-Equity/2016-Challenge/Implementing-a-health-in-all-policies-approach-with-health-equity-as-the-goal/. Accessed January 18, 2019.
72. Marmot M, Allen JJ. Social determinants of health equity. Am J Public Health. 2014;104:S517–S519.
73. W.K. Kellogg Foundation. Growth, productivity, revenues, output: the business case for racial equity. Available at: http://www.nationalcivicleague.org/wp-content/uploads/2018/04/RacialEquityNationalReport-kellogg.pdf. Accessed January 18, 2019.
74. Robert Wood Johnson Foundation. A new way to talk about the social determinants of health. Available at: https://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023. Accessed January 18, 2019.
75. U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health. Available at: https://www.healthypeople.gov/2010/document/pdf/uih/2010uih.pdf. Accessed January 18, 2019.
76. Turner A. The business case for racial equity. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ncr.21263. Accessed January 18, 2019.
77. Jones CM. The moral problem of health disparities. Am J Public Health. 2010;100:S47–S51.
78. Bartick MC, Jegier BJ, Green BD, Schwarz EB, Reinhold AG, Stuebe AM. Disparities in breastfeeding: impact on maternal and child health outcomes and costs. J Pediatr. 2017;181:49–55.