Towards health equity: the urgent need for upstream intervention studies in gastroenterology and hepatology

Health inequity is a major challenge to achieving broader social equity and a just society. Interventions to reduce health inequity can be directed at downstream determinants of health, such as individual health-care needs, midstream determinants, such as neighbourhood conditions, or upstream determinants, such as structural racism and discrimination.¹ For example, interventions to reduce inequities in colorectal cancer mortality in African-American people could include mailing reminders about faecal immunochemical tests (downstream intervention); providing patient navigation, transportation, or other direct aid to access health-care services (midstream intervention); or changing laws that redistribute power, wealth, and resources, including health insurance (upstream intervention).²

In the USA, the National Institutes of Health acknowledge the impact of structural racism and discrimination on health, and have dedicated funding to scientific investigation in this area. Structural racism and discrimination are broadly described as discrimination based on race or ethnicity, gender, sexual orientation, disability status, national origin, and other physical characteristics or health conditions. Research has linked structural racism and discrimination with poor patient outcomes in gastrointestinal diseases. For example, racial bias in mortgage lending, also known as redlining, has been associated with decreased colorectal cancerspecific survival time in Black women, independent of area of residence.³ Although such research is rare outside the USA, redlining has been reported in other nations, including Canada and the Netherlands, and similar outcomes among Black women in these settings would be unsurprising.^4,5

Interventions that address upstream determinants to reduce inequities in gastroenterology and hepatology are needed, but such interventions are sparse and difficult to study. Effects of policy changes that reduce structural racism and discrimination might not be measurable for years and existing studies are largely historical. Despite positive examples of community-specific interventions, such as church-based educational programmes, there is a paucity of published data to quantify their effect and support broader implementation.⁶ Additionally, although health (eg, the US Affordable Care Act of 2010) and social policies (eg, the US Civil Rights Act of 1964) have led to more equitable care over time, racial, ethnic, and socioeconomic disparities persist.⁷

Our group set out to perform a scoping review of the literature for upstream interventions aimed at reducing structural racism and discrimination in gastroenterology and hepatology health outcomes. Although we approached this project with modest expectations, the absence of published studies of upstream interventions was truly grim. Our forthcoming work, which includes studies that describe the association between structural racism and discrimination, law or policies, and outcomes of gastrointestinal conditions has resulted in a few preliminary findings. First, the impact of structural racism and discrimination is often underestimated. For example, reduced access to care is often attributed to cultural beliefs, without discussion of the structural racism and discrimination that might have restricted health-care access. Second, there are challenges to designing and analysing interventions. Many midstream interventions are at a single centre and target a specific socially excluded group, without a control group, limiting understanding about the intervention effect. Third, some studies attribute health differences to genetic or physiological differences, and consideration of structural racism and discrimination is entirely omitted from the analysis.

Tools for measuring structural racism and discrimination are evolving and complex. Measures of association, such as the racial bias in mortgage lending index, redlining index, and location quotient for racial residential segregation, are relatively new and might be unfamiliar to clinical researchers.⁸ The scientific power of these measures remains to be fully realised. Although we have identified novel uses of these tools for structural racism and discrimination in gastroenterology and hepatology, quantification of the effect of genderbased discrimination or other forms of discrimination is lacking. Additionally, these quantitative measures would benefit from qualitative research to contextualise findings. Use and refinement of these tools will be essential to overcome scepticism of the link between discriminatory policies and specific health outcomes.^9,10

Paula Braveman has remarked that “intervention research often seeks to identify the magic bullet that will yield results on its own”.⁹ There is no single magic bullet to eliminate health disparities, particularly when structural racism and discrimination are apparent. As a research community, we must promote studying the impact of structural racism and discrimination on gastrointestinal health and implementing evidence-based interventions, not only as pertaining to race and ethnicity, but also for other personal statuses. The literature in this area is overwhelmingly US-based; more international data are needed. Shedding light on how local, organisational, and governmental policies affect distribution of resources and specific gastrointestinal outcomes should be helpful. Health equity advocates must mobilise the political will needed to promote relevant upstream changes. Ultimately, interventions to reduce health inequities in gastroenterology, hepatology, and beyond, by addressing upstream determinants, will benefit everyone, not just historically excluded populations.