Addressing the Elephant in the Room: Structural Racism and Health Disparities in the Philippines

Introduction

The popular English idiom, “the elephant in the room,” refers to something so obvious that no one seems to notice or wants to address it because of the potential for social, political, or personal shame or danger (Merriam-Webster, n.d.). Furthermore, people refuse to acknowledge this obvious issue and ignore it because doing so would involve taking responsibility for a problem or risk they would rather not face. This idiom can also refer to a universal truth everyone knows; however, nobody wants to bring it up for fear of offending others or embarrassment(Roberts, 2020).

Structural racism is at the intersection of the social determinants of health and health disparities because it causes unequal opportunities for education, employment, income, wealth accumulation, residential quality, and healthcare(Bailey et al., 2017). One’s socioeconomic status is directly related to one’s health. Negative consequences on health can be traced back to the intricate web formed by structural racism’s interplay with ethnic identity, social determinants, and material well-being(Churchwell et al., 2020). Structural racism and health disparities are even more pronounced in developing countries like the Philippines where the power of the majority is concentrated in the hands of the few, and the health of the underprivileged is not prioritized(Crear-Perry et al., 2021).People from historically oppressed groups suffer the most from the physical and mental health consequences of racism, which include chronic discrimination, constant stress, and depression(Lin et al., 2021).

This advisory is a call to action to bring attention to this injustice and identify strategies and solutions to eliminate structural racism and health disparities in the Philippines. Despite what some may believe, we have confidence that addressing structural racism is both possible and rewarding and is crucial for reducing health disparities.

Structural Racism and Health Disparities in the Philippines

Recent reports show that providing citizens in the Philippines with even the most fundamental of medical care services remains a significant obstacle. This is largely because medical facilities are either unavailable or unevenly distributed across the country. There is also a significant gap in the availability of primary care facilities within 30 minutes for at least 50% of the population(Flores et al., 2021). Intuitively, the wealthy have better access to private sector health care than the poor. Manila’s new hospitals are among the best in Southeast Asia, yet, the hospital population has barely grown in 20 years. While 20%–30% of the population has access, 70–80 million poor Filipinos do not. Many people rarely or never see a doctor(Flores et al., 2021).

A recent study also revealed that approximately 13% of Filipinos are of indigenous descent, numbering anywhere from 10–15 million (Duante et al., 2022). However, the country’s high infant and maternal mortality rates and high fertility rates show that this population has substantially lower health outcomes (Dela Rosa et al., 2022). This creates problems for those who have especially limited access to this basic care or for those living in generally poor health conditions. Although 77.1% of indigenous peoples in the Philippines were aware of the national health insurance program, 46.2% were not members, suggesting that their financially dependent children were not adequately covered (Duante et al., 2022). Likewise, children from indigenous communities are particularly susceptible to the health risks associated with the COVID-19 pandemic.

Clearly, structural racism leads to health disparities which cause “differential access to the goods, services, and opportunities of society by race” and shapes social values and power structures, keeping people in their place(Cogburn, 2019). Equality is, at its core, a concept of fairness. It is a recognition of the fact that not everyone has the same starting point. There have been times when “equity” has been used interchangeably with “equality,” but achieving true equity takes much more time and thought. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable disparities and historical and contemporary injustices to help eliminate health and healthcare disparities(Penman-Aguilar et al., 2016). Adjustment methods are necessary for appropriate solutions because these methods and strategies consider unequal burdens and existing inequities.

Using the Socio-Ecological Model to Promote Public Health

Due to their immense potential to improve health and save lives, effective health promotion frameworks have been at the forefront of public health research and practice. The Socio-Ecological Model demonstrates how a multi-level approach can highlight the most important societal and ecological influences on health-related behavior(Javed et al., 2022). Due to the complex interplay between various factors and how each influence the other, it is important to act on multiple levels such as public policy (such as local, state, and federal legislation), the environment (such as cultural norms and the physical environment), organizations (such as communities), individuals (such as members of one’s family or one’s social network), and one’s internal factors (such as one’s own physical and mental health, risk factors, behavior, and genetics).Therefore, the framework can be used as a basis for public health research and the development of interventions for health promotion and betterment, as well as for critically assessing and understanding the range of factors that increase risks for health disparities(Jilani et al., 2021).

Many causes of health disparities lie in systemic or societal factors that are difficult to change unilaterally. Therefore, initiatives to eliminate disparities and advance health equity must consider the complex interplay of multiple influencing factors(Jilani et al., 2021). For example, critical influences, such as the physical environment, access to health care services, and psychological experiences based on socio-environmental factors, are interconnected with factors like race/ethnicity and socioeconomic status (e.g., discrimination, victimization, stress). Equally contributing to health disparities are socioeconomic status, geographical location, environmental factors, and social and cultural norms and practices(Javed et al., 2022). Likewise, many discoveries that have led to better population health result from investments in biological, social, and behavioral sciences, which have significantly increased knowledge of disease genesis, prevention, detection, and treatment. Therefore, affecting population health improvements requires understanding the injuries and diseases that cause health burdens and the risks associated with injury and disease.

Using a Multi-level Approach to Reduce Structural Racism and Health Disparities

Scientific and medical advancements have not benefited everyone equally, and efforts to reduce economic and racial/ethnic disparities have not always been successful(Penman-Aguilar et al., 2016). The underlying mechanisms for these differences are complex and multifaceted. Similarly, many approaches to improving minority health and health disparities have fallen short due to their narrow focus on a single factor or factor at the individual level. Therefore, it is crucial to systematically plan and evaluate the effectiveness of multi-level interventions in these populations(Williams et al., 2019). Healthcare providers, researchers, community leaders, and health policymakers will benefit because they can construct more efficient and effective methods, discover multi-level causal elements that contribute to intervention efficacy, and understand the dynamic interactions between these elements within and across intervention levels(Vaughan et al., 2020).

Recognizing the level(s) of intervention needed and developing them in light of current data and behavioral theory are the foundations of effective interventions. However, treatments that target multiple aspects of the socioecological context tend to be more sustainable and effective over the long term(Johnson-Agbakwu et al., 2022). Also, although policy interventions can affect at any level, policies require implementation at the individual, interpersonal, organizational, and environmental levels. Therefore, clinicians and researchers should consider the interplay of all levels of the socioecological framework when thinking of ways to increase the adoption of best practices and the execution of disease prevention interventions to enhance clinical decisions and promote health(Javed et al., 2022).

Finally, expanding research into health problems that cause the highest disease burden, like cardiovascular disease, is widely acknowledged as crucial to enhancing developing countries’ health and development status. In 2013, the World Health Organization warned that it would be difficult to achieve health goals unless developing countries became research producers(Roberts, 2020). Therefore, maximum effort should be made to conduct this research in developing nations like the Philippines to better define the issues that need to be addressed, propose culturally congruent and cost-effective individual and collective interventions, investigate their implementation, and examine the barriers that prevent the implementation of recommended strategies(Johnson-Agbakwu et al., 2022).

Sadly, many low-income countries like the Philippines still lack the health research capacity necessary to produce a local evidence base that can be used to inform policy and advance public health(Dela Rosa et al., 2022). Thus, despite years of international cooperation and investment, developing countries’ health problems will remain a persistent challenge.

A Call to Action

As the largest and arguably the most patient-centered sector of the health workforce, nurses and public health researchers must take the lead in combating structural racism and health disparities. The first step of effective leadership is to continue one’s education and that of one’s peers, students, workers, patients, and communities. There are various ways to get involved in politics and shape policy. Sometimes the smallest of changes can make the most significant difference. For example, there is a strong connection between local sustainability and preparedness and larger health system, hospital, or university concerns(Lucyk, 2020). In addition, It is essential to think back on past events and draw lessons from both triumphs and failures to improve the odds of success for future capacity building. This exercise would encourage conversation and thought, possibly leading to new ideas, and provide a uniform perspective for reviewing previous capacity-building efforts(Johnson-Agbakwu et al., 2022).

Primary preventive measures are urgently needed in the Philippines as part of a larger public health policy package(De Vero et al., 2021). Health agencies at all levels, national, regional, and local, must coordinate their efforts to make public policy(Jilani et al., 2021). To meet the growing demand for information and motivation among residents to adopt more preventative health practices, health clinics and community health workers in rural areas will need to increase their health education efforts. More training and programs to supervise and monitor community health workers will increase the community’s trust and reliance on their abilities to provide basic healthcare and referrals. More funding from the Philippine Department of Health and other multi-level initiatives and programs is necessary to remove local health promotion barriers(Williams et al., 2019). Likewise, the Philippines needs to strengthen its secondary and tertiary care disease management initiatives. Chronic disease management is crucial to maintaining a healthy population and controlling healthcare costs(De Vero et al., 2021). However, this will not be easy without a strong primary care infrastructure.

In conclusion, we must give structural racism and health disparities our undivided attention, investigate its adverse effects on social determinants and individual health and well-being, and respond appropriately. The Philippine government can and should go further upstream and identify structural racism as a historical driving factor of health disparities(Vaughan et al., 2020). To ensure that everyone in our society is treated fairly by the law and the criminal justice system and has access to affordable, high-quality health care, we must eradicate structural racism and health disparities and focus on reducing health risk factors(Dela Rosa et al., 2022). Healthcare providers, researchers, community partners, and health policy leaders in the Philippines must identify effective and inclusive strategies and solutions and work together to eliminate structural racism and health disparities(Neely et al., 2020). To eliminate these negative outcomes and implement effective programs to promote health for all people, we need to improve the scientific understanding of structural racism and its consequences on health(Roberts, 2020). Intractable disparities will continue to perpetuate without policy makers’ deliberate allocation of opportunities, resources, and support, as well as public health professionals’ questioning, researching, analyzing, and reporting critical information.