Health Equity and the Fierce Urgency of Now

Rob Abbott, CEO & Executive Director, ISPOR

Martin Luther King’s famous “I Have a Dream” speech from 1963 was a clarion call for racial and social justice. I have lived my entire life in the long shadow of that speech. Among other things, it inspired me to dedicate my life to improving human welfare globally. One of the many phrases that King immortalized on that August afternoon was “the fierce urgency of now:”

We are now faced with the fact that tomorrow is today. We are confronted with the fierce urgency of now. In this unfolding conundrum of life and history, there “is” such a thing as being too late. This is no time for apathy or complacency. This is a time for vigorous and positive action.

Whenever I am asked why I have a pervasive bias for action, I refer people to the above words. I believe that in too many matters that affect human welfare there is such a thing as being too late. Health equity is a good example—and an example that is rooted in many of the racial and social injustices that King fought so gallantly throughout his life. Marcia Anderson, MD, Medical Officer of Health in the Canadian province of Manitoba, executive director of Indigenous academic affairs with the Ongomiizwin-Indigenous Institute of Health and Healing, and Vice-Dean of Indigenous Health, Social Justice, and Anti-racism at the University of Manitoba, puts it well:

From now on, instead of ”vulnerable people,” I’m going to use the phrase ”people we oppress through policy choices and discourses of racial inferiority.“ It’s a bit longer but I think will help us focus on where the problems actually lie.

It’s become popular of late to speak of “social determinants of health,”ⁱ and while I appreciate the sentiment, I think Anderson is both more honest and more accurate in naming the underlying or foundational conditions that have created so many of the health “inequities” that exist across the globe. We know that people’s living conditions—and ultimately their health—are made worse by discrimination, stereotyping, and prejudice based on sex, gender, age, race, ethnicity, or disability, among other factors. Discriminatory practices are often embedded in institutional and systems processes, leading to groups being under-represented in decision making at all levels or underserved.ⁱⁱ

I also believe that health economics, with roots in welfare economics,ⁱⁱⁱ has a vital role to play in addressing these inequities. I’m therefore very pleased to see this themed issue of Value and Outcomes Spotlight, with an emphasis on health equity and the ways in which it needs to be addressed. I might add that ISPOR’s new vision—a world in which healthcare is accessible, effective, efficient, and affordable for all—pays more than a nod to the imperative of improving health equity across the globe.

Health equity is a long-standing concern in global healthcare. While terminology varies between disciplines and countries, a common denominator is a shared interest in reducing unfair differences in health, healthcare, and financial protection from the costs of healthcare. In May 2017, a report published by the Robert Wood Johnson Foundation defined health equity as the conditions in which:

Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and healthcare.

Equally, the Foundation defined several steps that should be taken to achieve health equity:

1. Identify important disparities which can impact an individual’s health
2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be as healthy as possible
3. Evaluate and monitor efforts using both short- and long-term measures
4. Reassess strategies in light of process and outcomes and plan next steps
   

I’m pleased to report that ISPOR is actively engaged in work that supports these steps and makes health equity an essential element in everything we do as a professional society. In particular, we boast a Special Interest Group (SIG) centered on health equity research that is advancing equity-informative methods and data for health economics and outcomes research (HEOR) that help to reduce unfair differences in health. At the same time, a new ISPOR SIG is focused on accelerating global access to medical innovation in low- and middle-income countries. In doing so, both groups have considerable potential to address a significant social welfare gap and improve the ability of millions—and potentially billions—of people to be as healthy as possible.

Our field of HEOR is grounded in the creation of scientific evidence on the efficacy of health interventions. It is also grounded in the curation of real-world evidence that brings the patient experience and voice to bear on healthcare decision making. Put another way, our combination of patient and disease-level data, empirical approach to scientific study, and strong track record of providing useful and timely information to support decision making make HEOR a key lever to improve health equity. Consider how these powerful and persuasive capabilities might be brought together to support evidence-informed action in 3 areas:

1. Ensuring that high-quality and effective healthcare services are available, accessible, and affordable to everyone when they need them.
2. Ensuring that the structural determinants of health are more widely understood—and addressed—to improve daily living conditions for as many people as possible.
3. Ensuring that health outcomes and health service delivery are monitored to detect inequities early and to facilitate corrective action.
   

As the articles and stories in this themed issue of Value & Outcomes Spotlight make clear, HEOR is already making a difference—and is poised to do more. I am often asked to define HEOR in a way that is “relatable” to a lay audience. I like to frame my response by saying that “HEOR is about getting the best that medicine has to offer to the largest number of people at reasonable cost.” I might add that in doing so, it enables more people across the world to attain their full potential for health and well-being. This is an explicit acknowledgement that HEOR has a key role to play in confronting the “fierce urgency of now” that is making health equity the norm across the world.

ⁱ   Social determinants of health (SDH) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.

ⁱⁱ   Racial disparity in the United States healthcare industry, for example, has been a long-standing research topic. While quality and access has improved in the United States thanks to initiatives like the Affordable Care Act, there is still a gap in the quality of care different groups receive.

ⁱⁱⁱ  Welfare economics applies microeconomic techniques to evaluate the overall well-being (welfare) of a society. A key feature of the field is its assessment of the distribution of resources and opportunities among members of a particular society. This, in turn, can have a significant influence on the ways in which governments may choose to intervene to improve social welfare.