Social Justice as a Tool to Eliminate Inequities in Kidney Disease
2021; Elsevier BV; Volume: 41; Issue: 3 Linguagem: Inglês
10.1016/j.semnephrol.2021.05.001
ISSN1558-4488
Autores Tópico(s)Healthcare Policy and Management
ResumoSummary: Kidney disease has disparate effects on racial and ethnic minority groups, who have higher rates of chronic kidney disease and generally poorer outcomes. These disparate rates and outcomes have been attributed to social determinants of health; however, these social determinants of health are related to governmental and societal structural barriers that have created inequities not only in kidney disease, but also in other chronic diseases and in maternal/fetal health outcomes. The societal barriers to health equity include income inequality, inadequate education, environmental injustice, mass incarceration, and the enduring effects of the legacy of slavery. The approach to reducing disparities in kidney outcomes must be viewed through the lens of social justice to address these societal barriers. Summary: Kidney disease has disparate effects on racial and ethnic minority groups, who have higher rates of chronic kidney disease and generally poorer outcomes. These disparate rates and outcomes have been attributed to social determinants of health; however, these social determinants of health are related to governmental and societal structural barriers that have created inequities not only in kidney disease, but also in other chronic diseases and in maternal/fetal health outcomes. The societal barriers to health equity include income inequality, inadequate education, environmental injustice, mass incarceration, and the enduring effects of the legacy of slavery. The approach to reducing disparities in kidney outcomes must be viewed through the lens of social justice to address these societal barriers. The attention of health care providers was focused sharply in 2020 on inequities in medicine, brought into sharp relief by the coronavirus disease 2019 (COVID-19) pandemic, which exposed vast differences in risk and outcomes based on race, income, neighborhood, and socioeconomic status.1Tai DBG Shah A Doubeni CA Sia IG Wieland ML The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States.Clin Infect Dis. 2021; 72: 703-706Crossref PubMed Scopus (230) Google Scholar,2Macias Gil R Marcelin JR Zuniga-Blanco B Marquez C Mathew T Piggott DA COVID-19 pandemic: disparate health impact on the Hispanic/Latinx population in the United States.J Infect Dis. 2020; 222: 1592-1595Crossref PubMed Scopus (62) Google Scholar Although these inequities have been known to health care disparity investigators, they were not as well known among those not steeped in the literature or among the lay public. Lessons learned from the COVID-19 pandemic may be applied to every discipline in medicine, because these inequities exist across every discipline. African American mothers have higher rates of maternal complications, including death, than do white mothers, even after controlling for income and education.3Hirshberg A Srinivas SK Epidemiology of maternal morbidity and mortality.Semin Perinatol. 2017; 41: 332-337Crossref PubMed Scopus (54) Google Scholar,4Ozimek JA Kilpatrick SJ Maternal mortality in the twenty-first century.Obstet Gynecol Clin North Am. 2018; 45: 175-186Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Similarly, infant mortality rates for African American babies are significantly higher than those of white babies.5Ely DM Driscoll AK Matthews TJ Infant mortality rates in rural and urban areas in the United States, 2014.NCHS Data Brief. 2017;; : 1-8PubMed Google Scholar This review focuses on lessons learned from the pandemic and how they may be applied to understand and remedy the inequities in rates and outcomes of kidney disease. Although this review focuses on the United States and the legacy of slavery and its long-term after-effects, racial and ethnic disparities in health outcomes are not a uniquely American phenomenon. As an example, in the United Kingdom, black women have an almost four times higher rate of maternal mortality compared with white women, while women of Asian descent have a maternal mortality rate approximately two times greater than that of white women.6Bunch K Kurinczuk JJ Knight M Maternal mortality in the UK 2016-18: surveillance and epidemiology. National Perinatal Epidemiology Unit, University of Oxford;, Oxford2020Google Scholar A casual observer in an American dialysis clinic would notice very quickly the striking difference in the number of patients of color relative to white patients, especially considering the racial and ethnic composition of the underlying population in which the dialysis clinic lies. As early as 1982, Rostand et al7Rostand SG Kirk KA Rutsky EA Pate BA Racial differences in the incidence of treatment for end-stage renal disease.N Engl J Med. 1982; 306: 1276-1279Crossref PubMed Scopus (340) Google Scholar were reporting disproportionately high rates of end-stage kidney disease (ESKD) attributed to hypertension among African American patients. These differences also have been noted for many years in the annual report of the US Renal Data System8US Renal Data System2020 USRDS annual data report: epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2020Google Scholar (Table 1). The overall prevalence of chronic kidney disease at all stages in the United States was 15.7% for non-Hispanic whites, 16% for non-Hispanic blacks, and 11.9% for Hispanic/Latinos according to data from the 2015 to 2018 National Health and Nutrition Survey. Regardless of apolipoprotein L1 risk allele status, African American patients tend to progress faster toward ESKD compared with white patients.9Parsa A Kao WH Xie D Astor BC Li M Hsu CY et al.APOL1 risk variants, race, and progression of chronic kidney disease.N Engl J Med. 2013; 369: 2183-2196Crossref PubMed Scopus (463) Google Scholar In 2018, the adjusted prevalence rate for ESKD among African Americans was 5,854.8 per million compared with 1,703.5 per million for white Americans.8US Renal Data System2020 USRDS annual data report: epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2020Google Scholar The adjusted prevalence was 3.4 times greater in African Americans in 2018, down from 3.8 times higher 10 years earlier, indicating some progress in the 10-year period in reducing the excess risk of ESKD. The leading cause of ESKD remains diabetes. Similar disparities in rates of kidney disease have been reported in other racially and ethnically diverse nations, including the United Kingdom, Canada, and Australia (Table 2).Table 1ESKD Incidence and Prevalence 20188US Renal Data System2020 USRDS annual data report: epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2020Google ScholarIncident ESKD, Cases per MillionPrevalent ESKD, Cases per MillionBlack/African American834.15,854.8American Indian or Alaska Native504.43,163.4Asian355.72,275.3White312.71,703.5Incidence and prevalence of ESKD in 2018 by race as defined in the US Renal Data System.Abbreviation: ESKD, end-stage kidney disease. Open table in a new tab Table 2Rates of ESKD in Other Racially and Ethnically Diverse NationsNationDisparityAustralia6.2× greater risk for indigenous people52Hoy WE Mott SA McDonald SP An update on chronic kidney disease in Aboriginal Australians.Clin Nephrol. 2020; 93: 124-128Crossref PubMed Scopus (2) Google ScholarUnited Kingdom3× to 5× greater risk for blacks and South Asians53Caskey F, Dreyer GKidney health inequalities in the UK an agenda for change.2018https://kidneyresearchuk.org/wp-content/uploads/2019/09/Health_Inequalities_lay_report_FINAL_WEB_20190311.pdfGoogle ScholarCanada2.5× to 4× greater risk for First Nations people54Gao S Manns BJ Culleton BF Tonelli M Quan H Crowshoe L et al.Prevalence of chronic kidney disease and survival among aboriginal people.J Am Soc Nephrol. 2007; 18: 2953-2959Crossref PubMed Scopus (82) Google ScholarAbbreviation: ESKD, end-stage kidney disease. Open table in a new tab Incidence and prevalence of ESKD in 2018 by race as defined in the US Renal Data System. Abbreviation: ESKD, end-stage kidney disease. Abbreviation: ESKD, end-stage kidney disease. African American patients, despite having a higher burden of ESKD, are 24% less likely to receive a kidney transplant and less likely to be referred for pre-emptive transplantation.10Patzer RE Paul S Plantinga L Gander J Sauls L Krisher J et al.A randomized trial to reduce disparities in referral for transplant evaluation.J Am Soc Nephrol. 2017; 28: 935-942Crossref PubMed Scopus (47) Google Scholar,11Gander JC Zhang X Plantinga L Paul S Basu M Pastan SO et al.Racial disparities in preemptive referral for kidney transplantation in Georgia.Clin Transplant. 2018; 32: e13380Crossref PubMed Scopus (19) Google Scholar Around the world, access to dialysis and transplantation varies by nation and by national wealth. An international survey of the global capacity for delivering kidney care showed that dialysis was available to more than 50% of eligible patients in only 70% of surveyed nations capable of offering chronic dialysis.12Bello AK Levin A Lunney M Osman MA Ye F Ashuntantang GE et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar Kidney transplantation was available to more than 50% of eligible patients in 29% of surveyed nations capable of offering kidney transplantation.12Bello AK Levin A Lunney M Osman MA Ye F Ashuntantang GE et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar Within the United States, where renal replacement therapy is offered to the vast majority of patients as a covered benefit through Medicare, undocumented immigrants, who do not qualify for Medicare, may not be offered dialysis at all, or on a limited, as-needed, basis, depending on the state in which the patient resides.13Rodriguez R Cervantes L Raghavan R Estimating the prevalence of undocumented immigrants with end-stage renal disease in the United States.Clin Nephrol. 2020; 93: 108-112Crossref PubMed Scopus (10) Google Scholar Diabetes itself is a leading contributor not only to kidney disease, but also to cardiovascular events, which drive much of the excess mortality in chronic kidney disease. There is a 60% higher likelihood that African American adults will have been diagnosed with diabetes by a physician compared with non-Hispanic whites.14Chow E Foster H Gonzalez V McIver L The disparate impact of diabetes on racial/ethnic minority populations.Clin Diabetes. 2012; 30: 130-133Crossref Scopus (81) Google Scholar Black patients also suffer from other complications of diabetes including retinopathy and peripheral arterial disease at higher rates than non-black patients. The rate of amputations among black patients with diabetes is approximately three times higher than among white patients.15Presser L The black American amputation epidemic.ProPublica. 2020. [2021 January 9]; (Available from:)https://features.propublica.org/diabetes-amputations/black-american-amputation-epidemic/Google Scholar The burden of retinopathy and amputations, when added to ESKD, significantly reduces the patient's independence and ability to earn a livelihood, and increases the morbidity burden, as evidenced by frequency of hospitalization. Hypertension prevalence and rates of control vary among races and ethnicities. Among all adults in the United States, the prevalence of hypertension was 57.1% among non-Hispanic blacks, 43.6% among non-Hispanic whites, and 43.7% among Hispanics.16Fryar CD Ostchega Y Hales CM Zhang G Kruszon-Moran D Hypertension prevalence and control among adults: United States, 2015-2016.NCHS Data Brief. 2017;; : 1-8Google Scholar Furthermore, non-Hispanic white Americans are more likely to have controlled hypertension (50.8%) compared with non-Hispanic blacks (44.6%). Poorly controlled hypertension also contributes to excess cardiovascular morbidity and mortality through hypertensive heart disease, congestive heart failure, and cerebrovascular accidents. A superficial explanation for the differences in rates of ESKD between African Americans and white Americans is that African Americans have higher rates of diabetes and hypertension, as well as poorer access to medical care, resulting in delayed diagnosis and treatment of the underlying chronic kidney disease. COVID-19 and the social unrest that unfolded after the murder of George Floyd at the hands of law enforcement forced clinicians to think more deeply and delve into the underlying root causes for the vast disparities in rates and outcomes of kidney disease and other chronic illnesses. In its 2002 report, the Institute of Medicine defined health care disparities as "racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention."17Institute of MedicineUnequal treatment: confronting racial and ethnic disparities in health care. 2003; : 780Google Scholar This review highlights some of the root causes that are not related to biology, clinical appropriateness, or patient preference(Fig. 1).. At the end of the Civil War, the majority of African Americans in the United States were living in the southern states where they had been recently enslaved. Medical care in this largely agrarian economy was by and large nonexistent for both blacks and whites. As modern medicine began to develop in the 20th century, several factors were occurring simultaneously that limited access to medical care for African Americans. First, the Jim Crow system of forced segregation limited opportunities for care. Hospitals and doctors' offices were forced to have separate waiting rooms and treatment areas for colored--as they are called at the time--patients, many of whom preferred not to seek medical attention rather than to be humiliated into using these separate and unequal waiting rooms and treatment spaces. Second, the Ku Klux Klan and other white supremacist groups began a reign of domestic terrorism in which thousands of African Americans were murdered, often by lynching, to subjugate the black population and keep them from enjoying the rights of citizenship, namely the right to vote. Third, the criminal justice system was used to round up and force African American men into unpaid labor based on false charges or vague crimes such as vagrancy.18Alexander M The new Jim Crow: mass incarceration in the age of colorblindness. The New Press, 2010Google Scholar As a result of these harsh living conditions, African Americans began to move from the rural South to the cities of the Northeast, Midwest, Great Plains, and West to have more opportunities for a livelihood. However, they would find themselves marginalized again, this time within segregated ghettos of New York, Chicago, Detroit, Cleveland, Boston, Omaha, Los Angeles, and other cities where access to health care remained limited.19Wilkerson I The warmth of other suns. Random House, New York, NY.2010Google Scholar African American doctors in all parts of the country were excluded from privileges at most hospitals until the latter part of the 20th century. They were forced to see patients only in their private offices and cede their care once they required hospitalization to the white doctors who had privileges, or they had to band together and come up with the resources to build their own hospitals. Hospitals usually had separate wards for African American patients, particularly in the Jim Crow–era south. Grady Hospital, which remains the safety net hospital for the city of Atlanta, GA, often may be referred to as the Gradys by older African Americans who remember it essentially as two separate hospitals, one for black patients and another for white patients.20Lovasik BP Rajdev PR Kim SC Srinivasan JK Ingram WL Sayed BA "The living monument": the desegregation of Grady Memorial Hospital and the changing South.Am Surg. 2020; 86: 213-219Crossref PubMed Google Scholar Barnes Hospital, the major teaching hospital of Washington University in St. Louis, relegated black patients to a basement ward until 1963, per Morrison.21Morrison AR Reflections of a naïve trainee to Barnes Jewish Hospital/Washington University in 1970-my first 25 years.J Am Soc Nephrol. 2021; 32: 543-544Crossref PubMed Scopus (1) Google Scholar Medical schools in the United States did not accept African American students in large numbers until the 1970s, in the first wave of diversity and inclusion efforts. Edwin C. J. T. Howard and Thomas Dorsey were the first black students to graduate from Harvard Medical School in 1869. However, by 1972, there were only 64 total African American alumni from Harvard Medical School and Harvard School of Dental Medicine.22Harvard Medical School. 50 years of diversity and inclusion at HMS and HSDM. [cited 2021 January 31]. Available from:https://hms.harvard.edu/news-events/celebrating-50-years-diversity-inclusion/50-years-history.Google Scholar State university medical schools generally were closed off to African American students such that most African American doctors in the United States, until recently, were graduates of two historically black medical schools: Meharry Medical College in Nashville, TN, and Howard University College of Medicine in Washington, DC.23Norris KC Baker RS Taylor R Montgomery-Rice V Higginbotham EJ Riley WJ et al.Historically black medical schools: addressing the minority health professional pipeline and the public mission of care for vulnerable populations.J Natl Med Assoc. 2009; 101: 864-872Crossref PubMed Scopus (15) Google Scholar,24Sullivan LW Suez Mittman I The state of diversity in the health professions a century after Flexner.Acad Med. 2010; 85: 246-253Crossref PubMed Scopus (84) Google Scholar Black children through most of the 20th century were educated in separate and unequal public schools. In rural areas in the South, there were often no schools unless communities came together to fundraise and get one of the highly coveted Rosenwald schools through the philanthropy of Julius Rosenwald.25Deutsch S You need a schoolhouse. Northwestern University Press, Evanston, IL, 2011Google Scholar The Rosenwald schools educated thousands of children in the rural South, but they still were underfunded compared with their white counterparts. Black children suffered through schooling in dilapidated buildings with inadequate heat and no indoor plumbing. Black teachers were paid less than white teachers despite doing the same work for the very same school system. The landmark 1954 Supreme Court decision in Brown v. Board of Education, which declared that separate schools were inherently unequal, set the stage for lower courts to force schools across the nation to integrate; however, many schools remained de facto segregated through the 1970s. In small towns across the South, white families joined together to build segregationist academies to avoid sending their children to newly integrated public schools. Cities in the North and Midwest were as notorious in their opposition, sometimes violent, to court-ordered busing to achieve integration across segregated neighborhoods. The image of white Bostonians attacking a school bus carrying black children into South Boston showed the nation that segregation was not a phenomenon limited to the South.26Formisano RP Boston against busing.. The University of North Carolina Press, Chapel Hill, NC, 1991Crossref Google Scholar Louise Day Hicks, a Boston lawyer and school committee member, rose to prominence and eventually a seat in Congress, in opposition to busing to achieve school desegregation.27Zezima K Louise Day Hicks dies at 87; led fight on busing in Boston. The New York Times, 2003Google Scholar Although some cities, towns, and rural areas did achieve success in achieving integration, white residents rapidly fled the cities to suburbs with independent school districts. Housing discrimination practices kept many of these suburban communities practically all white, leaving the city school systems educating almost exclusively non-white students. Despite gains in education and job opportunities following the Civil Rights Act of 1964, the Voting Rights Act of 1965, and the Fair Housing Act of 1968, income inequality remains a major barrier to security for African Americans. In 2016, African Americans at the median of income distribution earned 65% of what their white counterparts earned.28Kochhar R Cilluffo A Key findings on the rise in income inequality within America's racial and ethnic groups: Pew Research Center.2018https://www.pewresearch.org/fact-tank/2018/07/12/key-findings-on-the-rise-in-income-inequality-within-americas-racial-and-ethnic-groupsGoogle Scholar The great recession of 2008 and the COVID-19 pandemic hit communities of color harder than white communities in terms of job loss and income. The wealth gap between whites and blacks increased from 10-fold to 13-fold between 2010 and 2013.29Kocchar R, Fry R. Wealth inequality has widened along racial, ethnic lines since end of Great Recession 2014. [cited 2021 January 31], Available from: https://www.pewresearch.org/fact-tank/2014/12/12/racial-wealth-gaps-great-recession.Google Scholar Home ownership, a leading metric of accumulated wealth, had been increasing steadily until the 2008 recession, but has since decreased and has shown no signs of increasing.30Famighetti C Hamilton D Economic Policy Institute.2019https://www.epi.org/blog/the-great-recession-education-race-and-homeownershipGoogle Scholar Figure 2 shows that with the legacy of slavery at its base, income inequality has persisted across generations and is related directly to health care inequities.Figure 1Biologic differences, clinical appropriateness, and patient preferences account for a small amount of the differences in health outcomes among minority and nonminority populations. Social-based health care disparities and societal factors account for the rest. Reprinted with permission from Nicholas et al.55Nicholas SB Kalantar-Zadeh K Norris KC Racial disparities in kidney disease outcomes.Semin Nephrol. 2013; 33: 409-415Abstract Full Text Full Text PDF PubMed Scopus (80) Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) Food insecurity remains a major socioeconomic problem that was worsened by the COVID-19 pandemic–induced disruptions. Food insecurity is defined as the disruption of food intake or eating patterns resulting from a lack of money and other resources.31Nord M Food insecurity in households with children: prevalence, severity, and household characteristics. Economic information bulletin number 56. United States Department of Agriculture, Washington, DC, 2009Google Scholar Food insecurity may arise as a result of economic hardships, which may be episodic as in temporary unemployment, or sustained in circumstances of chronic joblessness and economic deprivation. Furthermore, neighborhoods populated by poor people may be food deserts, in which there are limited numbers of grocers selling nutritious foods.32Beaulac J Kristjansson E Cummins S A systematic review of food deserts, 1966-2007.Prev Chronic Dis. 2009; 6: A105PubMed Google Scholar In these neighborhoods, residents may find convenience stores with higher prices and lower-quality foods than are available in other neighborhoods. When there is adequate money to buy food, the lack of access to transportation to a high-quality food source further limits the ability to obtain nutritious foods. The ability to access high-quality foods and maintain a healthy diet may be linked directly to kidney disease and kidney health outcomes. The Dietary Approaches to Stop Hypertension diet, which is low in sodium and rich in fruits and vegetables, is associated with lower blood pressure than the typical Western diet. Diets that are low in acid production also may be associated with improved renal outcomes.33Crews DC Food as medicine for CKD: implications for disadvantaged populations.Clin Nephrol. 2020; 93: 36-41Crossref PubMed Scopus (3) Google Scholar Patients with chronic kidney disease and ESKD often are prescribed diets that are low in phosphorous, yet many of the highly processed foods sold in food deserts are very high in phosphorous additives used as preservatives.34Ritz E Hahn K Ketteler M Kuhlmann MK Mann J Phosphate additives in food–a health risk.Dtsch Arztebl Int. 2012; 109: 49-55PubMed Google Scholar Finally, maternal/fetal malnutrition, prematurity, and low birth weight are associated with reduced nephron numbers and subsequent development of hypertension and chronic kidney disease.35Luyckx VA Brenner BM Birth weight, malnutrition and kidney-associated outcomes–a global concern.Nat Rev Nephrol. 2015; 11: 135-149Crossref PubMed Scopus (152) Google Scholar In 2016, 12.3% of households in the United States were food insecure. As with many measures related to health, there were significant differences by race and ethnicity. Households headed by blacks and Hispanics had higher rates of food insecurity than the national average at 22.5% and 18.5%, respectively.36Coleman-Jensen A RM Gregory CA Singh A Household food security in the United States in 2016. Economic research report number 237. United States Department of Agriculture, Washington, DC, 2017Google Scholar Children living under these circumstances rely on school nutrition programs, access to which was limited during the COVID-19 pandemic because of school closures. The environmental justice movement that began in the 1980s called attention to the link between environmental hazards and adverse health outcomes. Poor people and communities of color were more likely to be exposed to environmental hazards and toxins than were their wealthier white counterparts in the same cities and towns.37Evans GW Kantrowitz E Socioeconomic status and health: the potential role of environmental risk exposure.Annu Rev Public Health. 2002; 23: 303-331Crossref PubMed Scopus (690) Google Scholar It is well established that African Americans, particularly children, have disproportionately high rates of asthma, which may be tied to air pollution. Furthermore, poor air quality and high rates of smoking contribute to other chronic lung diseases such as emphysema, chronic obstructive pulmonary disease, and lung infections. A recent and highly publicized episode of environmental injustice occurred in Flint, MI. In 2014, Flint officials switched their water source from the Detroit city system to the Flint River. The water from the Flint River turned out to be highly corrosive, resulting in lead contamination of the water supply. Flint residents noticed and complained about the color, odor, and taste of the water, which had reached or exceeded the action level of 15 parts per billion for lead. Lead is particularly neurotoxic toxic to children and may lead to learning disabilities and behavioral problems.38Ruckart PZ Ettinger AS Hanna-Attisha M Jones N Davis SI Breysse PN The Flint water crisis: a coordinated public health emergency response and recovery initiative.J Public Health Manag Pract. 2019; 25: S84-S90Crossref PubMed Scopus (29) Google Scholar There were approximately 99,000 people in the Flint area who were affected by poor water quality as a result of the change in water source during this period. Of 7,306 children younger than age 6 who had their blood lead levels measured, 5% were increased at more than 5 ug/dL, compared with 3.1% before the water source switch.39Kennedy C Yard E Dignam T Buchanan S Condon S Brown MJ et al.Blood lead levels among children aged <6 years - Flint, Michigan, 2013-2016.MMWR Morb Mortal Wkly Rep. 2016; 65: 650-654Crossref PubMed Scopus (50) Google Scholar This lead contamination only exacerbated the socioeconomic problems of a city already reeling from the effects of de-industrialization. Approximately 42% of Flint residents live below the poverty line, and 63% are people of color.40Butler LJ Scammell MK Benson EB The Flint, Michigan, water crisis: a case study in regulatory failure and environmental injustice.Environmental Justice. 2016; 9: 93-97Crossref Scopus (55) Google Scholar In Lowndes County, AL, a different type of environmental injustice has led to the resurgence of hookworm, a parasite of extreme poverty, long thought to be eradicated. Using molecular diagnostic techniques, investigators found that among 55 stool samples tested from Lowndes County residents, 34.5% were positive for Necator americanus, or hookworm. They also noted that 42.5% of households reported exposure to raw sewage.41McKenna ML McAtee S Bryan PE Jeun R Ward T Kraus J et al.human intestinal parasite burden and poor sanitation in rural Alabama.Am J Trop Med Hyg. 2017; 97: 1623-1628Crossref PubMed Scopus (54) Google Scholar This parasite problem relates back to the larger issue of extreme poverty. More than half of the households in Lowndes County have no septic system or have a septic system that is inadequate. Because of the soil conditions in what is known as the Black Belt of Alabama, conventional septic systems do not work. A more expensive septic system is needed that costs up to $30,000 in a county where the median annual income in 2016 was $27,000. Septic system failure therefore is common, with many homes experiencing sewage back-ups through bathtubs and toilets whenever rain falls.42EJI's Catherine Flowers testifies before congress about environmental racism: equal justice initiative. [cited 2021 January 31]. Available from:https://eji.org/news/ejis-catherine-flowers-testifies-congress-about-environmental-racism.Google Scholar In addition to parasites, this exposure to raw sewage carries numerous attendant health risks to vulnerable populations. Mistrust of the health care system has many root causes and is evident today in marginalized communities by vaccine hesitancy. First, there is a history of segregated, separate, and unequal care. Older African Americans still remember segregated wards and hospitals where African American doctors, in the rare communities that had them, were excluded from hospital privileges. In the Tuskegee syphilis study, conducted without informed consent through the early 1970s, men with syphilis were not given appropriate treatment so that the natural history of untreated syphilis could be observed by the study investigators.43White RM Unraveling the Tuskegee study of untreated syphilis.Arch Intern Med. 2000; 160: 585-598Crossref PubMed Scopus (72) Google Scholar These men were allowed to infect their partners with no thought given to the adverse impact on scores of other individuals. The story of Henrietta Lacks, whose cells were immortalized for commercial and research use without her consent, is a well-documented case that has exacerbated mistrust of the medical system.44Skloot R The immortal life of Henrietta Lacks. Crown Publishing Group, New York, NY, 2010Google Scholar What health care professionals have generally referred to as social determinants of health are in fact the result of societal and governmental policy decisions that have resulted in inequities in health outcomes. It is incumbent on the medical community to advocate for societal and governmental change to eliminate the health care disparities that arise from societal inequities. Education remains fundamental to allowing individuals to rise out of poverty. However, as long as education remains largely funded by state and local property taxes, poor communities will have schools that underperform relative to wealthier communities. As educational attainment increases, health literacy also will increase, which can have a significant impact on health outcomes. Poverty, income inequality, inadequate housing, and environmental injustice all are closely linked. Advocacy for governmental policies that will eliminate these inequities are critical to improving health outcomes. Health care institutions must lead by example in making sure that all employees from professionals to environmental service workers, food service workers, and others are paid a living wage. A diverse workforce that represents the population it serves is not only good for representation, but also for health outcomes. A recent publication has highlighted that African American babies have better outcomes when there is infant–physician racial concordance.45Greenwood BN Hardeman RR Huang L Sojourner A Physician-patient racial concordance and disparities in birthing mortality for newborns.Proc Natl Acad Sci U S A. 2020; 117: 21194-21200Crossref PubMed Scopus (76) Google Scholar Health care workers who understand the language and culture of their patients may be able to subtly influence health behaviors in ways that other clinicians cannot. Efforts must be made to increase the numbers of medical students and medical school faculty from under-represented communities. In 2018, only 3.6% of the faculty at US medical schools were black or African American, and only 5.5% were Hispanic, Latino, or of Spanish origin.46Diversity in Medicine. Facts and figures 2019Association of American Medical Colleges, Washington, DC.2019Google Scholar Engagement with trusted partners within the community is critical to reaching vulnerable populations who may mistrust the health care system. Health navigators who help patients through complex health systems may be able to improve outcomes in chronic kidney disease and other chronic conditions.47McBrien KA Ivers N Barnieh L Bailey JJ Lorenzetti DL Nicholas D et al.Patient navigators for people with chronic disease: a systematic review.PLoS One. 2018; 13e0191980Crossref PubMed Scopus (64) Google Scholar Community workers who check in with patients to make sure that they understand how to take their medication and manage side effects may be able to significantly impact adherence to treatment.48Kim K Choi JS Choi E Nieman CL Joo JH Lin FR et al.Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: a systematic review.Am J Public Health. 2016; 106: e3-e28Crossref PubMed Scopus (170) Google Scholar,49Coleman CM Bossick AS Zhou Y Hopkins-Johnson L Otto MG Nair AS et al.Introduction of a community health worker diabetes coach improved glycemic control in an urban primary care clinic.Prev Med Rep. 2021; 21101267Crossref PubMed Scopus (1) Google Scholar Finally, trusted community members, for example, barbers, have been shown to be able to improve outcomes in hypertension.50Victor RG Lynch K Li N Blyler C Muhammad E Handler J et al.A cluster-randomized trial of blood-pressure reduction in black barbershops.N Engl J Med. 2018; 378: 1291-1301Crossref PubMed Scopus (171) Google Scholar Similar efforts with other trusted community members may be helpful in improving outcomes in chronic kidney disease and other chronic diseases. Governments at all levels, national and local, well resourced and poorly resourced, must make the elimination of health inequity a top priority by investing at a level commensurate with their ability in programs and strategies aimed toward this goal. The Institute of Health Equity's Report, "Build Back Fairer: The COVID-19 Marmot Review" enumerates a series of recommendations to reduce health inequities that may be applied across nations with varying governmental structures and degrees of national wealth (Fig. 3).51Marmot M Allen J Goldblatt P Herd E Morrison J Build back fairer: the COVID-19 Marmot review. Institute of Health Equity, London, England, 2021Google Scholar Partnerships among health care professionals, government leaders, industry leaders, think tanks, and nongovernmental organizations will be essential to make progress in eliminating inequities that have been generations in the making.
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