Dear friends,

Almost everywhere I look in health care these days, people are talking about equity. And many are not merely talking about it but trying to do something about it. That’s great news. But the effectiveness of their efforts is likely to be limited by a stubborn fact: few are applying a structural lens to this work.

A structural lens reveals that inequities are not simply the unfortunate results and by-products of large forces in society, such as income inequality, structural racism, and generational poverty. Rather, inequities are harms against people. They are harms done by design. And they require structural solutions. 

Take, for example, the story of Mrs. M, which I often share with clients and audiences. Mrs. M is a single mother of two, who works a low-wage job and also cares for her ailing mother. She has type II diabetes and mild atherosclerotic heart disease, and despite having insurance spends $2,000 a year on out-of-pocket healthcare costs. At the end of last month she was admitted to the hospital after nearly passing out at work. Diagnosis: low blood sugar, directly caused by the combined effect of diabetic medications and end-of-the-month food insecurity. 

Before we launch a new social needs referral platform or farmer’s market to “solve” Mrs. M’s problem, it’s worth applying a structural lens. Do we consider Mrs. M’s suffering a result of structural violence—the ways in which our systems and social arrangements put people in harm’s way? For example, how local food apartheid increases her risk of food insecurity and preventable hospitalizations, or the way healthcare profiteering increases the prohibitive healthcare costs that Mrs. M has to manage? Or is it just a typical day at the hospital? Would our health plans, or our health system-based population health or quality and safety teams, whose central job is to identify adverse outcomes and prevent harm, even consider Mrs. M’s experience a form of harm? 

Alas, despite a few notable exceptions, the answer is no. Notwithstanding a surge in healthcare’s interest in health equity, we’ve become so inured to inequities that we don’t yet recognize them as harm. This is how structural violence works. It is normalized, and thus invisible, in our society, even as it disproportionately harms and traumatizes racially marginalized groups and people with low incomes. But these events start to take a much clearer shape when we understand them as systematic harms happening because of structural inequity.

What changes when you apply a structural lens to the pursuit of health equity? Almost everything. To start, we don’t just focus on achieving the quadruple aim—we help achieve it by recognizing how our own systems ignore or perpetuate structural violence and inequities, and taking steps to identify, provide redress for, and prevent these inequities—through work within our walls and through our support and active participation in structural solutions.  

We’ve been working with clients and partners across the country to help apply this structural lens to health equity work, from health systems in an AMA-led peer network for quality and safety leaders to leaders in the California Improvement Network, with whom we developed a Toolkit to Advance Racial Health Equity in Primary Care. 

We’ve learned that seeing through the structural lens helps them make inequities and stories like Mrs. M’s visible. It also demands that health system leaders ask and work with community leaders and experts to answer precise questions:

• As we identify health inequities, what specific forms of structural violence are driving these inequities and putting our patients, employees, and community residents in harm’s way? 
• To what extent are we identifying the harm that structural inequities cause in our hospitals, clinics, and communities every day? Or are we letting that harm remain invisible? 
• To what extent do we help address social needs and use that data to better understand racial or other forms of inequity? To what extent do identified patterns of health inequity vary by census block or tract?
• How did and how does our institution ignore and contribute to these health inequities and harm? How do we provide redress for any harm our institutions have caused?
• Who is working in our community to advance structural solutions to these inequities, and how do we support them?

When we ask ourselves those questions and answer them honestly, we cannot help but see the work before us transformed. For our patients, employees, and communities, a structural lens is the difference between moving upstream and advancing health equity in vain, or doing so with rigor and impact. 

With gratitude,

Rishi Manchanda, MD, MPH.