Confronting History and Health Inequities Together

Erica E. Marsh, MD, MSCI, FACOG | Image Credit: ihpi.umich.edu

“For whom was our health care system designed? On what populations is our normative data based?” These are some of the questions Erica E. Marsh, MD, MS, Reproductive Endocrinology and Infertility, University of Michigan, said guided her as she walked into work every day throughout her career in medicine.

Marsh is the vice chair of obstetrics and gynecology at the University of Michigan Medical School and a leading force in reproductive health research. Her groundbreaking work in fibroids, abnormal uterine bleeding, and health disparities has garnered millions in funding and reshaped the field.

With degrees from Harvard College and Harvard Medical School, Marsh's expertise lies in understanding reproductive disorders through a comprehensive lens, examining their social determinants and clinical impact. Her research focuses on patient experiences and community impacts.

In the “David and Rosemary Adamson Excellence in Reproductive Medicine Lecture: ‘The Silence of Our Friends’: At the Intersection of REI and Racism, Equity, and Inclusion” at the American Society for Reproductive Medicine (ASRM) 2023 Scientific Congress & Expo in New Orleans, Louisiana, Marsh fostered her experience and expertise to articulate the intricacies of health inequity as it impacts health care today.

In its broadest term, the US-centric definition of health disparity includes differences in the incidence, prevalence, mortality, burden of disease, and other adverse health conditions that exist among specific population groups. Whereas health inequities, Marsh explained, are systematic differences in the health status of different population groups which are unnecessary, according to the WHO definition.

“These are largely the results of social constructs vs genetics and biology,” she said.

Equity is often misunderstood as providing the same resources to everyone, but this approach doesn't necessarily address existing disparities, Marsh said. In the concept of equity, the goal is to provide individuals with the specific tools they need to access opportunities.

The Importance of History in Health Care

A significant feature of Marsh’s presentation included a historical overview, focusing on the dark chapters of American history, specifically slavery, its aftermath, and the subsequent fight for civil rights.

Awareness of the need for health equity has been growing. In 2021, the Blue Cross Blue Shield Association initiated a national health equity strategy after analyzing the data to determine any disparities within membership. Seun Ross, PhD, executive director of health equity for Independence Blue Cross explained the strategy targeted 4 areas in need of improvement: Maternal health, diabetes, cardiovascular conditions, and behavioral health.¹

“Health Equity is important. It is a business imperative and also a social mission, it is not either or, it is an ‘and,’ Ross said in an interview with the American Journal of Managed Care^Ⓡ (AJMC^Ⓡ). “There is a business case for health equity. Achieving health equity is important so that we can sustain the health care system. Without trying to achieve health equity, the health care system would undergo serious burdens that it may not be able to sustain.”²

While reflecting on recent and current events like the death of Breonna Taylor, the conflict across community school boards regarding critical race theory (CRT), and the January 6, 2021, United States Capital attack, Marsh asked: How did we get here?

A few years ago marked the 400th anniversary of Africans arriving in Jamestown, Virginia, beginning slavery in what would become the United States. She spoke of how the period was characterized by the enslavement and brutal treatment of Africans, driven by White supremacy and the economic benefits of free labor.

Marsh answered the question with a quote from James Baldwin:

History, as nearly no one seems to know, is not merely something to be read. And it does not refer merely, or even principally, to the past. On the contrary, the great force of history comes from the fact that we carry it within us, are unconsciously controlled by it in many ways, and history is literally present in all that we do. It could scarcely be otherwise, since it is to history that we owe our frames of reference, our identities, and our aspirations.

Marsh highlighted the contradiction between the foundational rhetoric of liberty and equality, as stated in the Declaration of Independence, and the harsh reality faced by enslaved Africans and Native Americans. The inhumane treatment persisted even after the importation of slaves became illegal, with deeply entrenched discriminatory practices and the rise of the Jim Crow era, perpetuating racial segregation and inequality.

She detailed significant events such as the Dred Scott case, where the Supreme Court ruled that neither free nor enslaved Africans could be US citizens, and the Civil War, which led to the Emancipation Proclamation and the eventual abolition of slavery through the 13th Amendment.

Despite legal advancements, the persistence of racial discrimination was illustrated through the rise of Jim Crow laws and the infamous Plessy v Ferguson case, where the Supreme Court upheld racial segregation in public spaces.

In recounting these historical events, Marsh showcased the dissent of Justice John Marshall Harlan, the lone voice against segregation in Plessy v Ferguson. According to Marsh, this history is important in understanding the enduring struggle for civil rights and racial equality in the United States, and the challenges faced by marginalized communities.

Taking Action With Counter Storytelling

Marsh addressed the permanence of racism, stating it's likely the most controversial tenet because it’s been shaped in the media as the belief that all White people are racist, when, in fact, that’s not what permanence of racism is.

“The permanence of racism says that our structures are inherently racist because of our historical context,” she said. “And then, the result is the privileging of some over others.”

Another tenant, counter storytelling, serves as a tool in challenging dominant narratives and reclaiming the voices and experiences of marginalized communities, Marsh explained. It stands as a response to historical and social contexts where stories have been predominantly crafted by individuals outside of these communities, often leading to misrepresentation, erasure, and distortion of their lived realities.

She stated that the concept of counter storytelling revolves around the idea of marginalized groups taking charge of their own narratives even when it’s easier to ignore them. In essence, it serves as a corrective measure to the majoritarian stories that have perpetuated stereotypes and biases.

“We can't ignore this,” Marsh said. “There's more at stake than our discomfort.”

Confronting Racial Inequality Together

“What does so much of what I talked about have to do with health disparities, with our patients, with society?” she asked. “Everything.”

Marsh challenged the audience to confront the uncomfortable truth about racial inequality, urging for active engagement in discussions about race, discrimination, and inclusion. She said the message is clear: Silence is no longer an option, and collective action is the key to achieving a more just society.

The importance of overcoming discomfort was emphasized when Marsh asked, “Why are we no closer to equality than we are?” To do so, she explained, individuals must find the courage to speak up, lift others, and acknowledge their biases. Unlearning and relearning are essential in this process, as they pave the way for genuine reflection and understanding.

“We're all part of the problem, so we're also all part of a solution,” she said.

Marsh shared a quote from Dr. Martin Luther King Jr, from which she titled her talk:

In the end, we will remember not the words of our enemies, but the silence of our friends.

“There are things more important than our discomfort, and there are things that are more important than even our fear—inclusion is more important,” she said. “Our care of our patients and loved ones is more important, and our existence tomorrow has to be more important than our fears today.”

Representation is crucial, and Marsh explained that to ensure inclusive representation in every room, everyone has a responsibility, regardless of their race or background.

“I need you to reflect on who's at the table. Who's part of this discussion? Whose voices am I not hearing, am I not considering?” she asked. “Whose voices can I not fill in the blank for because I don't have that lived experience?”

Before receiving a standing ovation, Marsh concluded by challenging the audience and those who have been putting forth efforts of inclusion, specifically within ASRM leadership, to continue doing so.

“I need you to make sure that even if I'm not in the room, that I'm in the room through you. I'm not calling anybody out, I'm calling us all in,” she said. “We have to do better, but when we know better, we can do better.”

Reference

1. Grossi G. Dr Seun Ross: BCBS Health Equity Goals Across 4 Focus Areas. AJMC. September 28, 2023. https://www.ajmc.com/view/dr-seun-ross-bcbs-health-equity-goals-across-4-focus-areas

2. Grossi G. Dr Seun Ross: Achieving Equity Is Necessary to Sustain the Health Care System. AJMC. September 22, 2023. https://www.ajmc.com/view/dr-seun-ross-achieving-equity-necessary-sustain-health-care-system