Promoting Health Equity: 5 Key Actions for Public Health Agencies

For many in public health, the term “equity” has become more of a buzzword than a call to action. Health equity in itself is not complicated—we want everyone to have “a fair and just opportunity to attain their highest level of health.”1 However, as we monitor progress, evaluate the impact of programs, and design interventions, we need to be mindful that we are operating in a system that was not designed to give everyone what they need; in fact, much of it was intentionally designed to withhold necessities from certain communities. Many of the institutions and systems that we view as innocuous were built on a legacy of anti-Blackness, cultural imperialism, oppression, and a hoarding of power and resources. Course correction is long overdue, and the public health community has an incredible opportunity to revamp the systems that are not serving us to advance health equity. The following key actions for promoting health equity demonstrate how public health agencies can make meaningful progress toward supporting the health, well-being, and resilience of their communities. Critically Reflect on How Policies, Institutions, and Systems Were Created to Maintain and Uphold White Dominant Culture Data are critical to drive decision making, allocate resources, and monitor health inequities. While data-driven resource allocation is generally positive, public health data infrastructure routinely excludes and/or underrepresents entire populations. The elimination, erasure, misclassification, and concealment of populations from public health data perpetuate structural racism and impede progress toward health equity. We cannot allocate resources to an inequity that is being masked by data gaps. To advance health equity, we must actively work to identify populations that are not adequately captured with existing systems and structures, fill gaps with missing information, and rigorously assess whether evidence based on a specific population is applicable to the population being served. Making participatory action approaches and qualitative work a default in your public health approach helps capture relationships and nuances that are not explained by quantitative data alone. For example, when developing a Request for Proposals, ensure inclusion of communities disproportionately burdened by health inequities in leadership roles on the development committee, attend existing community meetings to seek feedback, and talk to the people working directly with your populations to create more inclusive programming. When developing a report, ensure data are analyzed and interpreted by members of the communities described and include qualitative components. As public health workers, our job is to integrate this information into our approach and go beyond what we see on the surface. Intentionally Develop Meaningful Power-Sharing Partnerships With Communities Experiencing the Most Inequities The communities we serve are experts in their experiences. They have been living with the impacts of systemic racism and historical disempowerment, know the gaps in current practice, and live in a reality that does not wait for a change in leadership or political administration. Developing respectful power-sharing relationships with communities is essential. If you are in a position of identifying health challenges, directing resources, selecting programs and who they benefit, and evaluating outcomes, you have the power. Sharing power can mean shifting power to communities so they can make decisions about efforts that affect them and facilitating their ability to do so. This could involve writing a community advisory board into local legislation, ensuring its members are reflective of communities experiencing health inequities, that the board's scope has sufficient decision-making power or oversight so that they are not tokenized or disregarded, and that they are appropriately resourced and staffed. Wisdom and lived expertise are valuable—build in the same compensation structure, or greater, that you would for any other expert consultation. Center Action on the Most Structurally and Historically Disempowered and Those Who Are Most Vulnerable to Adverse Impacts Productive conversations often break down when debating resource allocation and investment. Centering actions on the most structurally and historically disempowered, and those who are most vulnerable to adverse impacts, benefits everyone and can often be achieved with low-effort, harm-reduction approaches. As such, centering racial justice is necessary to any intervention that advances health equity. The goal is not to help populations survive or to simply reduce health disparities; we should aspire to remove long-standing challenges that have prevented communities from thriving. We are seeing this with increasing integration of community health workers into public health practice and improved access to birthing doulas for Black birthing people.2 In both examples, long-standing barriers to culturally competent care are being mitigated by trusted providers who often share the same identities as the populations most at risk for the effects of structural racism. Be Observant and Cautious of Performative Equity Health equity should not be added at the end of a manuscript to better position it for publication or named in a policy intervention to make it more appealing to legislators. It is a thoughtful, evidence- and community-informed, strategic action led by the people most impacted by inequities and guided by those trained in racial justice and health equity. It is collaborative, open, and dynamic, with egos left at the door. It builds movements, starts good trouble, and transforms. Performative equity is dangerous in public health because it wastes valuable resources and time while hindering progress. While training is important, it should be paired with hiring people who share the identities and lived experiences of those most impacted by inequities into leadership roles. Recognize and Embrace Discomfort With the Unknown, and Break Free From the Notion of Perfectionism in Carrying Out This Work Conceptualizing and operationalizing a just society involve innovation and embracing what may seem impossible. As such, we must not allow discomfort with the unknown to stifle novel approaches and examinations. Learning from what has not worked, and building on the expansive knowledge base that exists from activists, Black feminists, Native communities, immigration experts, interdisciplinary researchers, public health professionals, scholars, and other key partners, is necessary to forge the path toward true equity, social change, and liberation. This column was adapted from the blog post, “Promoting Health Equity: Five Actions to Consider,” originally published on the de Beaumont Foundation blog at https://debeaumont.org/news/2023/promoting-health-equity-five-actions-to-consider/.