The Political Determinants of Health and Health Equity in the Aging Population

Abstract:

Within the discipline of public health, it is commonly understood that health outcomes are influenced by more than genetics and behavior. Many health problems can be firmly linked to a political determinant that created and is perpetuating health inequities in the United States. The COVID-19 pandemic has exacerbated these inequities, causing disproportionate outcomes, particularly for vulnerable and minoritized groups, including older adults. This article addresses the “isms” plaguing America’s health, while offering novel solutions to forge a path toward recovery and, ultimately, advancing health equity.

Key Words:

political determinants of health, racism, health equity, social justice, climate change, health disparities, race and ethnicity, data equity, inequities

The COVID-19 pandemic has revealed that the United States has a long-standing history of social injustices and inequities entrenched in all aspects of our society, including its healthcare system. It is not by chance that certain populations experience higher premature death rates than others, or that women of certain populations experience higher pregnancy-related deaths, or that factors such as poverty, crowded housing, inadequate transportation, food insecurity, and other community attributes put a community at higher risk for increased adverse outcomes.

Our political system has not valued each group equally, much less realized the long-term implications of such policies on the health of its citizenry. Many health problems can be firmly linked to political action or inaction (Dawes, 2020). Today, we understand that it is more than our genetics and behavior that influence our health outcomes. Conditions in the places where people live, learn, work, and play can have a wide range effect of health risks and outcomes (Centers for Disease Control and Prevention [CDC], 2021a).

Even worse is that longitudinally, repeated effects from social determinants of health (SDOH) and other psychosocial factors manifested in the form of chronic stress may accelerate the aging process physiologically and mentally for the general population (Braveman, P., et al., 2011).

But the real instigators of these unjust and inequitable outcomes are the Political Determinants of Health (PDoH), which involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that advance health equity or exacerbate health inequities (Dawes, 2020). These determinants and drivers, experienced across the life course, are what have given way to racism and health inequity in the aging population. As we continue to battle with the COVID-19 pandemic, these effects are magnified in the aging population. But before we can look beyond a post-pandemic America, we must understand the foundational nature of the political determinants of health and their systemic influence and structural concretization over time in the United States.

Inequities Built on a Strong Foundation of Racism in America

Enacted and implemented at the local, state, and federal levels more than 80 years ago, redlining was a racist policy initiated by the Home Owners Loan Corporation Act (HOLCA), which denied federal investments to certain neighborhoods based upon the discriminatory lending practices of the 1930s. This policy marked residents living in such neighborhoods as “too risky” for federally backed mortgages (Hobin, 2020). State and local governments worked with property appraisers assess neighborhoods in more than 200 cities for their “desirability,” based on race, graded from A to D, aligning grades with a color code; from the most desirable or “best” (White and nonimmigrant neighborhoods) labeled A or green, B or blue for “still desirable,” C or yellow for “definitely declining,” to the least desirable or “hazardous” (predominantly African American and immigrant) labeled D or red on maps (Mitchell & Franco, 2018). These color-coded “residential security” maps were adopted by private banking and mortgage companies, which denied homeownership to those same populations deemed undesirable. Neighborhoods with residents who were primarily Black or from other minoritized groups were deemed unfit.

The decades-long lack of governmental and non-governmental investment and maintenance in redlined neighborhoods contributed to social determinants and poor infrastructure. Greater poverty stemmed from lack of investment not only from a private residential perspective but also from a business perspective, denying commercial loans to these communities. This in turn stymied economic growth for residents, unlike their middle- and upper-class White counterparts who were enjoying economic prosperity from neighborhood investments. The trickle-down effect resulted in low quality housing lowering local property taxes, which affected school funding and led to low educational attainment. In addition, these neighborhoods were deprived of recreational green space, and often the site of industrialization, which caused increased pollution (Hobin, 2020).

The effects of this policy are still felt by those same populations, especially for the older population group characterized by financial instability, housing instability, and lack of homeownership, physical inactivity, and other adverse health effects (Dawes, 2020). Older adults who lived through those historic times today experience the compounded effects of the lack of intergenerational wealth transfer that comes from home ownership, and poorer health outcomes. Studies have shown that residents from redlined communities experience higher rates in preterm births, cancers, tuberculosis, and mental illnesses (Bailey et al., 2021).

Partisan Gerrymandering Can Also Be Linked to Health Inequities

Voting provides us an opportunity to address the long-term biological and societal consequences of the determinants of health and enables the decisions, research, programs, and policies that allow us to tackle these issues (Elliott et al., 2021). Yet, many individuals fail to recognize or take for granted voting’s impact on their health, well-being, and life expectancy. To ensure change, there must be increased voter engagement moving forward (Dawes, 2020).

Yet in most states, the drawing of congressional and legislative districts is handled by state legislatures, which creates a strong incentive for partisan lawmakers to draw districts in a way that benefits their party (Ingraham, 2019). It also allows partisan lawmakers to hold majorities in their statehouses and congressional delegations, despite winning only a minority of votes statewide (Ingraham, 2019).

Coupled with efforts to undermine minority votes, the Census plays a critical role in driving these results. The Urban Institute recently published findings on how the 2020 Census’s quality and data accuracy contributes to the unequal distribution of fairness (Elliott et al., 2021). The study indicates that many “hardest to count” communities (Black and Hispanic/Latinx individuals, renters, and non-U.S. citizens) were undercounted in the 2020 Census. When groups are inaccurately counted, unequal and unfair political representation and funding follows. Rectifying the inaccuracies of the Census process can advance availability of resources for health equity efforts (Elliott et al., 2021).

Gerrymandering is effectively disenfranchising millions of Americans, and this disenfranchisement is felt much more acutely among Black, Indigenous, People of Color (BIPOC) communities. It prevents a swath of Americans from engaging in the political process and developing the policies critical to reaching their optimal health.

Suffrage, or the right to vote, is a constitutional right that wields tremendous power and influence should we choose or be allowed to engage in it. Gerrymandering leads to the inequitable distribution of social, medical, and other determinants, and creates structural barriers to equity for population groups that lack power and privilege. This occurs when decision makers fail to listen to or understand the needs of the disempowered, leading to policies, programs, and practices that favor those in power. It prevents population groups from being afforded an opportunity to engage in and work on policy solutions to the issues affecting their communities and installs policy makers who will form decisions and drive an agenda on a macro level that may run counter to health equity (Dawes, 2020).

The Systemic Nature of Exclusion

Across the country, historic and ongoing displacement, exclusion, and segregation continue to prevent racial and ethnic minorities from reaching their full health potential across their lifespan, leading to lower life expectancies (Dawes, 2020).

Exclusion by Ageism

Age discrimination for White workers means the oldest workers face the strongest biases. For Black workers, age discrimination is at its peak for the youngest cohort, falls in middle age, and rises as workers near retirement. The data shows that as Black workers near retirement age discrimination rises. Employers may avoid hiring older Black workers due to well-documented health challenges that make them more vulnerable to health-related absenteeism. Black workers also face barriers to working longer that aren’t present for White workers. Black workers typically have less education and therefore are often working more physical, lower-quality jobs resulting in the lack of a 401(k) plan and an inability to save. The discrimination Black workers face ultimately gives them fewer assets and income in retirement (Van Dam, 2021). Also, many older African Americans had to use retirement accounts and savings to get through the job losses caused by the pandemic (Brooks, 2021), which, when combined with aforementioned issues, results in older African Americans and other minorities not having enough funds available to have the quality of life and the healthcare they require in the later years of life.

Overall, African Americans have endured generations of economic racism. This racism has resulted in low wages, low homeownership, and little-to-no savings or investments for Black people (Brooks, 2021). After a lifetime of racial and health inequities, Black elders are at risk of spending their last years with declining health, little income, and virtually no savings. Numerous studies have noted that Black Americans have worse health than their White counterparts, including chronic diseases and disabilities leading to shorter and sicker lives than white Americans (Brooks, 2021).

Black Americans depend heavily upon Social Security. According to the U.S. Social Security Administration, about 38% of older minority beneficiaries rely upon Social Security for 90% or more of their income, compared with 28% of White people (Brooks, 2021). The impact of these economic inequities has reverberated into multiple generations of poverty. This isn’t just about the wage gap, it’s about the intergenerational wealth gap and how inequality is exacerbated over time (Van Dam, 2021).

Exclusion by Racism

One blatant example of the systemic nature of exclusion in healthcare is the practice of race norming. Often referred to as “race correction,” “ethnic adjustment,” and “race adjustment,” race norming has since the 1990s been integrated into medical tools and often affects the older adult population, from kidney stone risk calculators to oncology risk assessment tools. Race is usually just one factor used to determine a person’s risk of illness or disease in these tools, factors like sex assigned at birth, severity of pains, and age are often also part of the algorithms (Cineas, 2021).

The healthcare industry’s understanding of race and human genetics has advanced considerably across the past 20 years, yet these insights have not led to clear guidelines on the use of race in medicine. The result is ongoing conflict between the latest insights from population genetics and the clinical implementation of race. Despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice. One subtle insertion of race into medicine involves diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity (Vyas et al., 2020). These calculators, and the implementation of race correction, are intended to individualize risk so that doctors do not apply a blanket decision to all patients and to remove physician bias when making complex decisions (Cineas, 2021).

Physicians use these algorithms to guide clinical decisions (Vyas et al., 2020). By embedding race into the basic data and decisions of healthcare, these algorithms propagate race-based medicine. While these calculators have certainly been helpful in detecting some patients’ risk for disease and medical complications, some doctors say the race correction element can be problematic (Cineas, 2021). Many race-adjusted algorithms guide decisions in ways that may direct attention or resources to White patients instead of members of racial and ethnic minorities (Vyas et al., 2020). They work on the racist premise that dates to slavery when persons of African ancestry were believed to be inferior to that of Whites, leading to the creation of algorithms that can end up harming patients of African descent (Cineas, 2021).

The understanding of race in healthcare has advanced considerably in the past two decades. Clinical tools used daily should reflect these new insights to remain scientifically rigorous. Equally important is to make healthcare a more antiracist field (Vyas et al., 2020), which involves revisiting how clinicians conceptualize race to begin with. One step in this process is reconsidering race correction to ensure that healthcare practices do not perpetuate the very inequities we aim to repair.

Exclusion by Sexism

Since the beginning of the pandemic, nearly 400,000 more women left the U.S. workforce than men, and according to the Bureau of Labor Statistics, all job losses in December 2020 were held by women. According to the National Women’s Law Center, by the end of 2020, the labor force included 2.1 million fewer women than it did in February of that year, just before the pandemic took hold in the United States (University of Pennsylvania, 2021). The Institute for Women’s Policy Research found that between February and December 2020, the number of employed White women dropped by 5.2%, compared to a 9.5% decline for Black women and an 8.3% decline for women who identify as Latina or Latinx (Institute for Women’s Policy Research, 2021).

While many have noted the disproportionate effect the pandemic has had on women in the workforce, there has been less focus on the harm it has done specifically to Black women. They have experienced the largest decrease in employment as a result of the COVID-19 pandemic (Smart, 2021). This decrease can be explained in various ways. The recession hit hard on economic sectors like tourism, retail, restaurant, and others that tend to employ large numbers of Black women. State and local governments, which also employ large numbers of Black women in good-paying jobs, saw outsized job losses, employing more than a million fewer workers in February 2021 compared with February 2020. Among demographic groups, Black women experienced the steepest drop in labor force participation and have had the slowest job recovery. At every education level, Black workers have higher unemployment rates compared to their White counterparts. Black workers with college degrees have unemployment rates similar to that of White workers with high school diplomas (Smart, 2021).

Black women face long-standing problems, including difficulty finding childcare, as well as shorter life expectancies and higher rates of maternal mortality. Black women are disproportionately burdened by chronic health conditions, such as anemia, cardiovascular disease, and obesity. Taken together, COVID-19 proved to be a double whammy for Black women, robbing them of their jobs as well as threatening their health (Smart, 2021).

Black women are especially vulnerable to adverse health and wealth issues as they outlive their partners and are more likely to be alone and isolated. They also often end up as long-term caregivers for ailing parents and spouses, or caring for grandchildren, forcing them to leave jobs and cut short careers. That means Black women are not paying into company-sponsored retirement plans such as pensions and 401(k) plans. It also reduces their payments into Social Security, which will reduce their monthly checks when they retire (Brooks, 2021). The COVID-19 pandemic has set gender parity back another 135.6 years for women to now be on equal footing with men (Suleymanova, 2021).

Pandemic Highlights a Greater Need to Advance Health Equity in Racially Diverse Groups

It is evident the United States was not prepared to respond to the COVID-19 pandemic, and its failure to address the structural and systemic racism fueled by political determinants has, once again, resulted in its continued inability to realize an equitable response for all its citizens whenever pandemics strike. We see the same groups of people on the downside of advantage and opportunity bearing the brunt of another devastating contagion, including racial and ethnic minorities, lower socioeconomic status individuals, people with disabilities, and immigrants.

Reports on the 1793 yellow fever epidemic and the 1918 influenza pandemic claimed Black communities were least impacted by the flu; however, this was during a time when preconceptions existed regarding Black people being immune to disease (Gamble, 2010). The smallpox outbreak of 1862–1868 claimed thousands of freed-slaves and Native American lives due to protocols that prioritized stopping the spread of the virus to soldiers but deemed the spread to freed-slaves and Native Americans as a “natural outcome” of emancipation (Downs, 2012). This notion carried over during the 1916–1955 Polio pandemic, which was further complicated by the “separate but equal” segregation laws of the time prioritizing White children over Black children in receiving the vaccine in segregated hospitals (Rogers, 2007).

For the past year, the COVID-19 pandemic has magnified health inequities in countries across the world. The United States is now the leading country impacted by COVID-19, with more than 38 million cases and more than 750,000 deaths (CDC, 2021b). Yet, this impact has been felt more disproportionately by our most vulnerable, marginalized, invisible, and already under-resourced communities. Life expectancy data from the CDC shows that as of July 2021, the decline is even greater than initially reported; all Americans lost 1.5 years, whereas the non-Hispanic Black community lost 2.9 years and the Latino community lost 3 years. American Indians and Alaska Natives lead the way in COVID-19 deaths at 21.5% (See Figure 1: Health Equity Tracker, 2021).

Figure 1. Total COVID-19 Deaths Per 100K People by Race And Ethnicity in United States

Source: Healthequitytracker.org. Date retrieved August 29,2021

In addition to race and ethnicity, the pandemic drastically impacted older adults, which were identified as a high-risk population at the onset of COVID-19 (Arias et al., 2021). This population represented a majority of COVID-19 hospitalization and deaths nationally, with state-level mortality trends almost doubling as age increases (see Figure 2: Health Equity Tracker, 2021).

Figure 2. Total COVID-19 Deaths Per 100K People by Age in United States

Source: Healthequitytracker.org. Date retrieved August 29,2021

PDoH in Aging Populations, Healthcare, and Climate Change

While the metaphor “silver tsunami” carries a negative connotation, it is important to understand the implications that an increasingly older population will have on America. Older adults are expected to live longer and is rapidly aging with an expected rise of 20% of its population by 2050, implying more will be relying on Medicare and long-term care services (James, Morton, & Dunn, 2015). These demands upon our healthcare system beg the question, is it prepared to handle the additional challenges brought on by an increasing population, a larger older population, and a more diverse population?

For the first time in U.S. history, minority children under the age of 15 have now become the majority (Frey, 2019). Yet in medicine, there is an astounding lack of diversity among healthcare workers, particularly physicians. While African Americans make up 13% of the U.S. population, they account for only 4% of all doctors. and less than 7% of medical students in the U.S. (Torres, 2018).

To abolish the practice of race norming previously discussed, we need minority clinicians to advocate. Clinicians of color are also targets of racism, encountering additional stressors such as being subject to racist behavior by their patients. Unfortunately, hesitancy to report these experiences, especially when clinician supervisors are White, is attributed to racial stress (Garran & Rasmussen, 2019).

A closer look at the demographics of the healthcare and public health workforce demonstrate that racial and ethnic minorities seem to be making little headway, or in some instances, regressing. This is particularly troubling given the fact that the Kaiser Family Foundation reported as of 2019, that the percentage of Black, Hispanic, and Asian healthcare providers were each only 10% of the healthcare workforce (Artiga, et al., 2019).

As of 2018, the American Geriatrics Society (AGS) reports that despite there being more than 7,000 geriatricians in the country, the current need is about 20,000 to properly treat this population of patients. Further, AGS states, “Knowing that we’ll need even more geriatricians—as many as 30,000 by 2030—we need creative and forward-thinking colleagues and approaches to expand the workforce (American Geriatrics Society [AGS], 2021). Given that the future of the healthcare workforce will be majority BIPOC individuals, it behooves us to invest in minority education today. Promoting diversity in healthcare by increasing minority clinicians can lead to cultural competency, rendering services to patients that are socially, culturally, and linguistically appropriate. We know that when a provider shares commonalities with patients, a higher level of trust is established leading to stronger engagement in the healthcare system.

Climate Change: Vulnerability in the Aging Population

Equally concerning is the impact climate change is having on health outcomes. The Summer of 2021 witnessed some of the most extreme weather, from more intense heat waves in the Pacific Northwest’s heat dome, to the Italian town of Sicily encountering an anticyclone named “Lucifer,” surpassing the hottest temperature previously recorded in all of Europe. Extreme heat exposure can increase the risk of illness and death among older adults, especially when they are living with chronic health conditions. Age is considered the greatest risk factor related to illness and death from extreme temperatures. High seasonal temperatures also have been shown to increase the odds of cognitive impairment and deficits in this subpopulation (Zeng, et al., 2010).

Complicating climate effects further is the decrease in air quality, attributed to scorching temperatures and dry climate causing raging wildfires in the West. According to the National Oceanic and Atmospheric Administration, wildfires emit substantial amounts of volatile and semi-volatile organic materials and nitrogen oxides, forming ozone and particulate matter adversely impacting air quality. Combined with existing pollutants, the result is a recipe for harmful exposure. Warming temperatures also make it easier for ground-level ozone to form and can lengthen the season of aeroallergens. These changes will increase the number of emergency department visits and hospital admissions, even for healthy older adults. Poor air quality worsens respiratory conditions common in older adults such as asthma and chronic obstructive pulmonary disorder (COPD). Air pollution can also increase the risk of heart attack in older adults, especially those who are diabetic or obese (U.S. Environmental Protection Agency [EPA], 2016).

Collectively, we have seen how these poor health outcomes owing to climate change have made minority and marginalized groups more vulnerable to COVID-19, which is concerning given the climate is likely to exacerbate preexisting conditions and the effects of future pandemics. The likelihood of pre-existing medical conditions and/or compromised mobility makes the older population, specifically the oldest old, more vulnerable due to their reduced ability to respond to extreme weather conditions and events attributed to climate change (Ann Arbor Office of Sustainability and Innovations, n.d.). This is a growing concern when considering that by 2050, people ages 60 and older will account for more than 21% of the global population (World Health Organization, 2021).

Equity Solutions

Despite the COVID-19 pandemic, the contentious political atmosphere dividing America, the structural "isms” embedded in our society, the tragedies occurring due to catastrophic climate change–induced events, there is a silver lining; collectively we have begun to talk about the injustices driving the political and social determinants of health. We now see public declarations made on topics that were once considered taboo, such as racism as a public health crisis (CDC, 2021a; Michigan.gov, 2020; Perry, 2021). Further, there is consensus from the public and private sector on the need to address these inequities (Executive Order No. 13995, 2021).

However, it is not enough to name inequities. We must drive the conversation upstream so that it results in action. We must ensure that every step we take adheres to a new vision, one in which America is viewed through an equitable lens. As we continue to navigate these murky waters and discuss the recovery of America in a post-pandemic world, we must create new tools to novel solutions.

Acknowledging and Communicating the Narrative Within the Population at Large

Across the United States, at the federal, state, and local levels, there has been an increased acknowledgement of the role health inequities have played during the COVID-19 pandemic. The impact that our medical and political responses have on these inequities received attention by acknowledging that our approach to, and allocation of, vaccinations, testing, antibody and antiviral treatments, equipment and personnel plays a significant role in perpetuating these inequities. While these issues have long been recognized within the field of public health, COVID-19 resulted in an internal movement within governing agencies to take responsibility and action (Office of Minority Health, HHS, 2021; Commonwealth of Virginia, 2021; Morehouse School of Medicine, 2021).

Communicating the Narrative Through Data Equity

Understanding the need to act, public health scholars at the Satcher Health Leadership Institute (SHLI) at the Morehouse School of Medicine recognized that data is vital for persuasive storytelling. In partnership with the CDC Foundation, Google.org, Gilead Sciences, the Annie E. Casey Foundation, Kessler Research Foundation, and AARP, SHLI launched a first-of-its-kind Health Equity Tracker in early 2021. The tool maps data on the trajectory of COVID-19 cases, hospitalizations, and deaths across the United States, including its territories, broken down by race and ethnicity, gender, and age, down to the county level, where available, as well as other comorbidities and socioeconomic factors.

The tracker brings to light the many faults in our existing data collection systems and standards by highlighting data gaps, missing, and unknown data through comprehensive map and graph visualizations. One stark example of this on the tracker is the “COVID-19 Unknown Data Map.” This map shows that 34.7% of COVID-19 cases reported an unknown race or ethnicity, which includes six states that do not publicly repo,rt any race or ethnicity data (Health Equity Tracker, 2022).

By presenting such data visualizations SHLI is responding to the misnomer that if there is no data, then there must not be a problem. The data or lack thereof, in turn, helps public health and healthcare leaders, policy makers and influencers, and business and community-based organizations better understand how to ensure disproportionately affected communities receive the targeted resources they need.

But misrepresentation or lack of representation in data is just one part of the problem. For real change to occur, policies must be pushed to ensure that data and all of its subcomponents are equitable, by standardizing data collection practices and reporting, standardizing which data to collect across all levels of government (from national down to local levels), ensuring the data includes all groups, making data more accessible by making it publicly available while minimizing bureaucracy, and making sure data is nonpartisan.

Rehabilitating the Relationship Between Institutions and Patients

COVID-19 served as the impetus to form health equity task forces and other structures to identify and address inequities in our government’s response to public health issues. The authority, scope, and intended duration of these programs varies greatly.

Established on January 21, 2021, the Presidential COVID-19 Task Force has served as an exceptional example of the power of collaboration among public health spheres. With a robust compilation of more than 316 recommendations developed by a diverse group of experts, its most recent report highlighted advanced recommendation imperatives that aim to respond to the present and future repercussions of the COVID-19 pandemic and beyond. Many of the proposed measures focus on special age populations, such as recommendation number 11, “Track and report on health outcomes for people in congregate and high-risk settings” (Office of Minority Health, 2021), number 38, “Accept all patients and offer community resources at Long COVID care centers,” and number 43, “Strengthen the care continuum for older adults and people with disabilities” (Office of Minority Health, 2021).

It is unclear if most of these structural recommendations and interventions will be implemented, let alone survive beyond this crisis. While the development of such task forces is an admirable, albeit limited, start, it is crucial and lays the groundwork for a more promising future in health equity.

Utilization of a “Place-based” Allocation Approach for Equitable Distribution of Resources

At the local level, cities have enacted efforts to ensure an equitable pandemic response. In Yonkers, NY, the city’s Health Equity Task Force, in collaboration with the local public health departments, established a Health Equity Score Card, identifying gaps and opportunities to close disparities adversely impacting Black, Latinx, and immigrant populations in that community. Recognizing increased COVID-19 rates within specific geographic locations and races and ethnicities in the community, the state implemented a targeted approach to their COVID-19 response (City of Yonkers, 2021). Like our equity tracker, use of mapping and overlaying known determinants of health help to identify the communities in greatest need of priority response. This facially neutral strategy, or one that seems to have no discriminatory impact based on how it is written, is more likely to pass constitutional scrutiny, while more efficiently using resources to target at risk populations.

Codifying Equitable Response Teams

Many states have established health equity task forces dedicated to an equitable state-level public health response during the pandemic. As of August of 2021, at least 40 states have some entity responsible for addressing health equity, with varying levels of authority and scope. In the Commonwealth of Virginia, the Equity Leadership Task Force, which is a public-private partnership, directs the Health Equity Work Group, part of the Commonwealth’s COVID-19 Unified Command. Virginia prioritized collecting accurate health equity data to ensure a data-driven approach to addressing the pandemic in that state, by targeting geographic areas at the highest risk of disparately negative health outcomes. Virginia embedded equity efforts into the infrastructure of the executive branch, codifying the requirement that the Governor’s cabinet must include a chief diversity officer, and requiring that officer to engage in disaster and public health response and planning. (Commonwealth of Virginia, 2021).

Daniel E. Dawes, JD, is executive director and associate professor; Christian M. Amador, MBA, MSc, is director of HealthEquity Initiatives; Maisha Standifer, PhD, MPH, is director, Health Policy; Mahia Valle, MBA, is senior communications specialist; Nelson Dunlap, JD, is chief of staff and assistant director; Sara Houston, JD, is senior policy advisor; Tonyka McKinney, DrPH, MPH, is Political Determinants of Health fellow, all at the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, GA. Michael Donnell is senior advisor of The Commonwealth Project in Boston, MA.

References

American Geriatrics Society. (2019, August). Current Number of Board Certified Geriatricians by State. Retrieved March 24, 2022, from www.americangeriatrics.org/sites/default/files/inline-files/Current%20Number%20of%20Board%20Certified%20Geriatricians%20by%20State%208%201%2019.pdf.

Ann Arbor Office of Sustainability and Innovations. n.d. Making the Connection: Climate Change and Older Adults. Retrieved August 26, 2021, from www.a2gov.org/departments/sustainability/Documents/Climate%20change%20and%20older%20adults%20flyer%20-%20FINAL.pdf.

Arias, E., Tejada-Vera, B., Ahmad, F. (2021). Provisional Life Expectancy Estimates for January through June, 2020. National Center for Health Statistics. February 2021. Retrieved March 6, 2022, from www.cdc.gov/nchs/data/vsrr/VSRR10-508.pdf.

Artiga, S., et al. 2020. COVID-19 Risks and Impacts Among Health Care Workers by Race/Ethnicity. The Kaiser Family Foundation. Retrieved August 31, 2021, from www.kff.org/report-section/covid-19-risks-and-impacts-among-health-care-workers-by-race-ethnicity-issue-brief/.

Bailey, Z. D., Feldman, J. M., & Bassett, M. T. (2021). How Structural Racism Works—Racist Policies as a Root Cause of U.S. Racial Health Inequities. The New England Journal of Medicine, 384: 768–73. doi: 10.1056/NEJMms2025396

Braveman, P., Egerter, S., & Williams, D. R. (2011). The Social Determinants of Health: Coming of Age. Annual Reviews of Public Health, 32, 381–98. doi:10.1146/annurev-publhealth-031210-101218

Brooks, R. (2021). Aging While Black: The Crisis Among Black Americans as They Grow Old. NAACP.Org. Retrieved December 11, 2021, from naacp.org/articles/aging-while-black-crisis-among-black-americans-they-grow-old.

Centers for Disease Control and Prevention. (2021a, March 10). About Social Determinants of Health (SDOH). Centers for Disease Control & Prevention. Retrieved March 6, 2022, from www.cdc.gov/socialdeterminants/about.html.

Centers for Disease Control & Prevention. (2021b, April 8). CDC Newsroom. Retrieved November 12, 2021, from www.cdc.gov/media/releases/2021/s0408-racism-health.html.

Cineas, F. (2021). “Race norming” and the long legacy of medical racism, explained. Vox, July 9. Retrieved March 6, 2022 from www.msn.com/en-us/sports/nfl/race-norming-and-the-long-legacy-of-medical-racism-explained/ar-AALXI1K.

City of Yonkers, New York. (2021) Mayor’s Health Equity Task Force. Retrieved March 6, 2022, from www.yonkersny.gov/government/mayor-s-office/initiatives/mayor-s-health-equity-task-force.

Commonwealth of Virginia. (2021). COVID-19 Equity Leadership Task Force. Retrieved March 6, 2022 from www.nga.org/center/publications/a-case-study-of-the-virginia-covid-19-equity-leadership-task-force-and-health-equity-working-group/.

Dawes, D. (2020). The Political Determinants of Health. Maryland: Johns Hopkins University Press.

Downs, J. (2012). Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. The American Historical Review, 118 (2), 520–1. doi.org/10.1093/ahr/118.2.520

Elliott, D., Martin, S., Shakesprere, J., & Kelly, J. (2021). Simulating the 2020 Census: Miscounts and the Fairness of Outcomes. Urban Institute. www.urban.org/research/publication/simulating-2020-census-miscounts-and-fairness-outcomes

Executive Order 13995, Federal Register 7193 (2021). Ensuring an Equitable Pandemic Response and Recovery. Retrieved March 24, 2022, from www.federalregister.gov/documents/2021/01/26/2021-01852/ensuring-an-equitable-pandemic-response-and-recovery.

Frey, W. H. (2019, January 24). Less than half of US children under 15 are white, census shows. In Brookings. Retrieved March 24, 2022, from www.brookings.edu/research/less-than-half-of-us-children-under-15-are-white-census-shows/

Gamble, V. N. (2010). "There wasn't a lot of comforts in those days:" African Americans, public health, and the 1918 influenza epidemic. Public Health Reports, 125(3), 114–122.

Garran, A. M., & Rasmussen, B. M. (2019, June). How Should Organizations Respond to Racism Against Health Care Workers? AMA Journal of Ethics, 21(6), E501. Retrieved June 16, 2021, from https://journalofethics.ama-assn.org/article/how-should-organizations-respond-racism-against-health-care-workers/2019-06

Health Equity Tracker. (2022). Satcher Health Leadership Institute. Morehouse School of Medicine. https://healthequitytracker.org/.

Hobin, V. (2020). Open access study reveals harmful effects of redlining on babies born three generations later. University of California-Berkley Library News, November 19. https://news.lib.berkeley.edu/redlining.

Ingraham, C. (2019). What is gerrymandering and why is it problematic? Washington Post, June 17. Retrieved March 6, 2022, from www.washingtonpost.com/business/2019/06/27/what-is-gerrymandering-why-is-it-problematic/.

Institute for Women’s Policy Research. (2021). Women and the COVID-19 Pandemic: Five Charts and a Table Tracking the 2020 Shecession by Race and Gender. www.jstor.org/stable/resrep28438?seq=1.

James, E., Morton, S., & Dunn, W. (2015). Addressing the Health Needs of an Aging America: New Opportunities for Evidence-Based Policy Solutions [White paper]. University of Pittsburgh Center for Caregiving Research, Education & Policy. www.healthpolicyinstitute.pitt.edu/sites/default/files/SternCtrAddressingNeeds.pdf

Michigan.gov. (2020). Whitmer—Governor Whitmer Signs Executive Directive Recognizing and Addressing Racism as a Public Health Crisis, Creates the Black Leadership Advisory Council, Aug. 5. Retrieved March 24, 2022, from www.michigan.gov/whitmer/0,9309,7-387-90499_90640-535762--,00.html.

Mitchell, B., & Franco, J. (2018). HOLC “Redlining” Maps: The Persistent Structure of Segregation and Economic Inequality. National Community Reinvestment Coalition. Retrieved March 20, 2022, from https://ncrc.org/holc/.

Morehouse School of Medicine. (2021). Georgia DPH Appoints Dr. Montgomery Rice as Chair of New COVID-19 Health Equity Council. Morehouse School of Medicine, February 25. Retrieved March 24, 2022, from www.msm.edu/RSSFeedArticles/2021/February/dphappointsvmr.php.

Office of Minority Health, U.S. Department of Health and Human Services. (2021). Health Equity Task Force. Retrieved March 24, 2022, from www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=100.

Perry, M. (2021). St. Petersburg moves one step closer to declaring racism a public health crisis. Spectrum Bay News 9, July 22. Retrieved March 24, 2022, from www.baynews9.com/fl/tampa/news/2021/07/22/st-pete-is-poised-to-declare-racism-a-public-health-crisis.

Rogers N. (2007). Race and the politics of polio: Warm Springs, Tuskegee, and the March of Dimes. American Journal of Public Health, 97(5), 784–95. doi.org/10.2105/AJPH.2006.095406

Smart, T. (2021). Black Women Workers Hit Hardest by COVID-19. USNews.Com, April 15. Retrieved November 12, 2021, from www.usnews.com/news/economy/articles/2021-04-15/black-women-suffering-the-most-from-covid-19-job-market-disruption.

Suleymanova, R. (2021). COVID sets gender parity back by a generation, report finds. Business and Economy News | Al Jazeera, March 31. Retrieved March 6, 2022, from www.aljazeera.com/economy/2021/3/30/covid-sets-gender-parity-back-by-a-generation-report-finds.

Torres, N. (2018). Research: Having a Black Doctor Led Black Men to Receive More-Effective Care. Harvard Business Review. Retrieved August 7, 2021, from https://hbr.org/2018/08/research-having-a-black-doctor-led-black-men-to-receive-more-effective-care.

U.S. Environmental Protection Agency. (2016). Climate Change and the Health of Older Adults. CMU.Edu. Retrieved November 12, 2021, from www.cmu.edu/steinbrenner/EPA%20Factsheets/older-adults-health-climate-change.pdf.

University of Pennsylvania. (2021). COVID-19 and women in the workforce. Penn Today, March 17. Retrieved March 6, 2022, from https://penntoday.upenn.edu/news/covid-19-and-women-workforce.

Van Dam, A. (2021). For Black workers, age discrimination strikes twice. The Washington Post, June 14. Retrieved November 12, 2021, from www.washingtonpost.com/business/2021/05/14/age-discrimination-black-workers/.

Vyas, D. A., Eisenstein, L. G., & Jones, D. S. (2020). Hidden in Plain Sight—Reconsidering the Use of Race Correction in Clinical Algorithms. New England Journal of Medicine, 383(9), 874–882. https://doi.org/10.1056/nejmms2004740

World Health Organization. (2021, October 4). Ageing and health. In World Health Organization. Retrieved November 17, 2021, from www.who.int/news-room/fact-sheets/detail/ageing-and-health.

Zeng, Y., Gu, D., Purser, J., Hoenig, H., & Christakis, N. (2011, September 20). Associations of Environmental Factors With Elderly Health and Mortality in China. American Journal of Public Health, 21(6), E501. doi:10.2105/AJPH.2008.154971