I recently finished Denis Johnson’s National Book Award–winning novel about the Vietnam War, Tree of Smoke. Toward the end of the book, the narrator quotes an aphorism that I found particularly apt for today: “Don’t interrogate your opportunities; it’s not what you do that you regret, it’s what you don’t do.”
In the book, this insight is meant as a personal philosophy, a way of thinking about one’s life and accomplishments, about decisions made and decisions not made. However, it could just as easily apply to organizations, particularly in healthcare.
For many years, healthcare organizations have faced a set of historically intractable problems, some of which have become far more apparent and intense in the 20 months since the onset of the COVID-19 pandemic, including dealing with the fallout of a public health system that is fragmented, understaffed, and wholly inadequate to the challenges brought forward by the pandemic.
A central problem, one that runs through public health, workforce, and many other issues, is the health and healthcare inequities arising from pernicious disparities based on individual’s race or ethnicity, as well as gender, sexual identity, age, disability, socioeconomic status, and geographic location.
The evidence of health and healthcare inequity is staggering. (The statistics cited in this article come from a new book called Unequal Cities, which I highly recommend.)
The mortality rate for Blacks is about one-quarter higher than for whites. In the United States as a whole, annual excess deaths of Black Americans due to higher Black mortality rates is a shocking 192 preventable deaths per day or 8 preventable deaths per hour. The number of years of life lost due to preventable death for Black Americans is 59% higher than for whites.
The mortality rate from heart disease is 30% higher for Blacks than for whites, and the mortality rate for cancer is 20% higher. Annually in the U.S. there are 32,883 more preventable deaths among Blacks than whites from heart disease and cancer.
These disparities vary significantly depending on where you live. The average difference in life expectancy for Blacks and whites among the 29 largest cities in the country is 4 years. However, in Washington, D.C., the difference is 12 years—a 73-year life expectancy for Blacks compared with 85 years for Whites. In San Francisco the difference is 10.5 years, in Los Angeles 9.5 years, and in Chicago 8.3 years. Mortality rates from heart disease for Blacks in Washington, DC, is 144% higher than for whites, compared with an 8% difference in Baltimore.
In this context, the notion of interrogating your options and regretting what you don’t do is not just philosophical. It has actual results on people's lives.
How much responsibility should healthcare organizations assume for solving the problem of health inequity? One view is that responsibility should be shared among the public sector, the private sector, and healthcare organizations. That is an understandable view, and is indeed the status quo. Health inequity is enormously complex and pervasive; it touches on agencies, companies, and individuals throughout the country. However, shared responsibility has not solved the problem, in part because there has not been a single point of accountability. No one has stepped up and said, We will be accountable.
Healthcare organizations need to simplify their thinking about health inequity. They need to say, One of our most crucial responsibilities going forward over the next decade is to solve this problem. We will not over-interrogate this opportunity, as healthcare organizations are prone to do. We are going to take all the necessary actions that we have the power and authority to take. And although we are more than willing to work cooperatively with all of the different constituencies we need to work with, we’re not going to wait. We're going to jump in and figure out how to solve this. When it comes to solving the problem of health inequity, we are not going to regret the things that we did not do.
