Why is a Holistic, Intersectional Approach to Public Health Essential for Eliminating Minority Health Disparities?
April is National Minority Health Month, which calls attention to the health disparities that persist among racial and ethnic minorities in the United States. Community members, legislators and educators are encouraged to explore new ways to close these health care gaps and create positive change for the populations affected.
Hortensia Amaro, former associate vice provost for community research initiatives, Dean’s professor at the USC Suzanne Dworak-Peck School of Social Work and professor of preventive medicine at the USC Keck School of Medicine, has over three decades’ experience in public health research. Her career has largely focused on minority and women’s health and public health initiatives, from HIV/AIDS prevention to treatment of substance use and mental health disorders in low-income Latina and African-American women.
Amaro’s forthcoming memoir, Head Over Heart, examines how historical influences, gender and socioeconomic factors shaped her identity and lived experience as a Latina refugee, psychologist, researcher and advocate for health equity. Tracing her journey through various life stages, this story relates the complexities of negotiating identity and developing agency in the face of adversity. A relentless questioner, Amaro finds a path forward through the integration and alignment of the heart and the head.
Over the past 36 years, Amaro has dedicated herself to improving minority health through public health research and initiatives.
The Intersectionality of Health Risks and Required Services
In the mid-1980s, while researching drug use and HIV/AIDS prevention among pregnant injection drug users and sex workers in highly disenfranchised Boston communities, Amaro came to recognize the powerful social and economic factors that shaped the nature of health risks among the women in her studies. Her award-winning 1995 article in American Psychologist—Love, sex and power: Considering women's realities in HIV prevention—shifted the conversation to HIV prevention for women by establishing the influence of social status and gender dynamics.
“I quickly found that HIV concerns were not priorities for these women, because their daily lives were defined by survival,”Amaro said. “Often they were homeless, survivors of abuse from childhood through adulthood and lacked the economic means to provide immediate care for their children or feed themselves. We also noticed a profusion of mental illnesses and trauma disorders. I realized we needed a more comprehensive approach to providing care that was responsive to the realities of inequality and marginalization that these Latina and African-American women faced daily.”
Amaro was inspired to apply for funding in order to create a more holistic program, one that would fully address the intersectional challenges facing women at greatest HIV risk. The Mom’s Project and Entre Familia, the first of several licensed substance use disorder treatment programs she launched, are still active today.
Her approach broke new ground with its gender-specific and integrated treatment of substance use and mental health disorders and trauma. Amaro’s Boston Consortium Model of Integrated Treatment was recognized for its superior outcomes by the Substance Abuse and Mental Health Services Administration and subsequently adopted by other providers.
The Impact of Community on Public Health Outcomes
Despite her success with this model, Amaro grew increasingly aware of the limitations of health care services that treat illness and then send people back to live in the same conditions that made them sick in the first place.
“The frustrating and re-emerging factor was that after the women, their children and everybody on the team had spent so much time on this intense work, we still could not control the conditions and resulting stressors that threaten long-term recovery,” Amaro said. “Those are the conditions of poverty, inequality, lack of resources in terms of income and job market readiness, housing availability and discrimination.”
In addition, the perpetual issues of violence, domestic abuse and availability of illicit drugs are seemingly insurmountable forces shaping the life course of those in the community, and they are issues that women must again face upon returning home from treatment programs. When treatment focuses on substance abuse to the exclusion of these other factors, women often find that they are not equipped to manage such stressors—the key to maintenance of recovery when they return to their communities.
Keenly aware of these continued threats to recovery, Amaro applied for and received funding from the National Institutes of Health (NIDA and NIAAA) to conduct a randomized clinical trial that would assess whether teaching women skills for managing stress improves post-treatment outcomes. The results of the study show that women find the intervention useful in managing stressors linked to relapse risk. Whether the intervention translates to lower relapse rates and improved health outcomes are key questions to be answered in analyses currently being conducted by Amaro and her team.
Health Equity and Improved Population Health Require a Fundamental Change
Despite the potential promise of this intervention, Amaro remains skeptical that individual level approaches can be effective in the face of chronic exposure to stressors and lack of opportunity stemming from inequitable social conditions.
Reducing the inequities in disease and mortality rates seen across populations, particularly in relation to minority groups, requires a shift in focus to the prevailing social conditions that place communities at risk for health problems (rather than on individual behaviors). Until the underlying factors impacting the health of minority populations—the disadvantaged and inequitable conditions under which people live, work and play—are addressed, no large-scale improvement in population health can occur.
“In public health, the metaphor of ‘pulling drowning people out of a river’ versus ‘going upstream’ to address what is causing them to ‘fall in the river’ is used to convey the importance of focusing our attention on the root causes of health inequities,” Amaro said.
While emergency healthcare services are essential, they help one individual at a time. They do not address the underlying factors that shape community conditions and contribute to health outcomes. These communities are exposed to disproportionately high rates of substandard housing and environmental hazards, and a dearth of quality public education and job opportunities, all of which are significant culprits in the creation and perpetuation of health disparities.
“While we are pulling one drowning person out of the river, a thousand more are being exposed to the risk of falling in the river,” Amaro said. Without addressing these underlying factors, we will have little meaningful impact on improving population health and reducing disparities.
Town and Gown Relationships
Recognizing the value of an intersectional lens that examines the many factors at play is essential to enact this foundational change. In addition, Amaro recommends a strategy that engages partners from varied public and private sectors and anchor institutions within and outside of health care. These include the housing, employment, education, transportation, faith, criminal justice, philanthropy and community service sectors.
“Anchor institutions such as universities and hospitals—especially those situated within or near highly disenfranchised minority communities—are uniquely positioned to put their financial and intellectual resources to work to achieve health equity,” Amaro asserts. In fact, such a shift is already underway, as evidenced by the recent focus on health equity initiatives by the Coalition of Urban and Metropolitan Universities, the National Academy of Medicine, the Robert Wood Johnson Foundation’s Culture of Health Program and the Democracy Collaborative.
There is great mutual benefit to be gained from the close alignment of “town and gown” visions, interests and strategies. For example, initiatives related to equity and inclusion within the university are generally confined to our institutional perimeters. What might we learn and gain by extending these initiatives beyond our walls?
To do so will require building authentic, transparent and accountable partnerships between academic institutions and communities, which has posed a significant historical challenge. For academic leaders, there is ‘no place like home’—their neighboring communities—as a starting point for examining if and how we are part of the problem, and how we can be part of the solution.