January 2024: Five Observations to Overcome Growing Resistance to Health Equity

Dear friends,

Each new year brings us renewed energy and commitment for the pursuit of health equity and justice. In 2024, we’ll need to be ready to apply it in particular ways.

This is because the equity landscape is shifting. The past three years have brought a surge of long overdue attention to inequity across the United States, with new equity commitments and investments by many leaders and health care institutions. Many more Americans have expanded their understanding of the social and structural forces that place people (especially people of color) in harm’s way and taken collective action to change those.

In many regards, the net balance of movement in society and the healthcare industry is flowing toward greater health equity. While there is still more room for improvement, the country has updated federal policies, national standards, and state regulations that now elevate health equity to an unprecedented level of priority. We have new leaders in newly created positions in health care tasked explicitly with improving healthcare equity and the social drivers of health equity. We have more public agencies, officials, and teams working to address racial injustice through policy, and a network of grassroots advocates ready to support and push them. But while there is much to celebrate, there is also reason for concern—because as leaders and teams press forward, they are increasingly running up against reactionary forces that push backward.

Let’s put this in perspective. Repeatedly throughout American history, great expansions of rights, access to justice, and opportunities have been followed by periods of reactionary contraction. The end of slavery and expansion of rights through Reconstruction were followed by restrictive Jim Crow laws. The expansion of federal protections and liberties in the Civil Rights Era was followed by an era of racialized mass incarceration. The expansion of healthcare coverage and government-funded foreclosure protections in the late 2000s was followed by the rise of a right-wing, nativist, and authoritarian movement in the U.S. As historians have found, instead of a steady, linear expansion of justice and opportunity, American democracy has expanded and contracted over the years. And now, the recent expansion of racial justice movements and institutional commitments to equity that followed the murder of George Floyd is meeting its own wave of reactionary resistance.

In the cultural and political realm, book bans, anti-transgender laws, and bans on diversity, equity, and inclusion programs at public universities are proliferating across multiple states. Within health care, a growing number of health equity leaders are contending with these external cultural forces, as well as facing contracting internal budgets and withering political support for the transformational work and resources required to improve and embed equity.  Beyond the vocal reactionaries and fearmongers in our culture who conspicuously define these moments of contraction, a growing number of health equity leaders and Upstreamists now also contend with the internal complicity of inaction (from decent people who are scared, intimidated, or overwhelmed into silence) and the complicity of delay (from the well-intentioned questioners who undermine health equity and justice work by asking whether we go “too far” by talking about structural issues and naming racism or go “too fast” by seeking timely redress and solutions to structural issues). In a recent era, Dr. Martin Luther King Jr. described this as “the appalling silence and indifference of the good people who sit around and say wait on time.”

This moment can feel very isolating for those of us pursuing equity. Health equity leaders, teams, and colleagues may be susceptible to the chilling effect that reactionaries seek and stay quiet to protect themselves. But history also teaches us that this reactionary phase is sadly predictable—and that we can survive and overcome it.

At HealthBegins, we are strengthening ourselves for this phase of the journey by remembering the deep truths that led us into this work to begin with. Our work is informed by these key observations:

  1. Health and social inequities are experienced as harm.
  2. Social arrangements, including structural racism, put some people in harm’s way.
  3. Equity is not just the absence of harm or unjust differences, it’s the presence of systems that promote and preserve healing, opportunity, and justice.
  4. Since structural violence and harm are spatialized, institutions need a portfolio of strategies to advance health and social equity that is place-based, outcomes-focused, and works across levels of change.
  5. Courageous leaders need support and solidarity to implement these strategies, and to transform their institutions, relationships, communities, and themselves in the process.

In moments like this, that fifth observation is critical. We combat isolation and overcome fearmongering by coming together. When we feel overwhelmed by reactionary forces, we derive strength and power from each other, in solidarity. In the face of obstacles, courage is collective.

In our strategic and implementation work with HealthBegins’ client partners, we intentionally seek to create spaces, systems, and supports to help health equity leaders connect across and within their institutions to navigate this moment together. We all need to do the same for those whose roles are not explicitly about health equity but are critical to it (such as in quality improvement, clinical care, or social services). Those of us in political environments less affected by contraction can seek ways to offer more support and solidarity to those who are.

One thing I’ve learned is that the internal transformation we undergo and the relationships we form in the pursuit of health equity are as important as the external transformation we seek in our institutions and social policies. As we launch into this new year and reflect on the legacy of Dr. King, let us fuel our shared strength by redoubling our commitment to create deliberate solidarity and “beloved community”—to connect directly with each other as we remember Dr. King’s words: “We can all get more together than we can apart. And this is the way we gain power. Power is the ability to achieve purpose, power is the ability to effect change, and we need power.”

May this year bring you—and us all—the power we need.


Rishi Manchanda, MD, MPH.

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