Why Ensuring Inclusive Healthcare Matters and How Equity Sequence® Can Help

by Suhlle Ahn

Healthcare is subject to the same patterns of bias that affect all areas of society. Whether intentionally or not, if you fail to include some groups of people in your decision-making and activities, it’s a sure bet those groups are being inequitably served. Just this month, for instance, a study revealed that Black Americans have had 1.6M excess deaths over 22 years.

Inclusive healthcare starts with an awareness that you can’t unsee inequities tied to healthcare once you know about them. And the need to understand how it happens—when and where—follows. So does the need to do something about it.

Whether it’s treatment, diagnosis, drug-development, or access, calls to consider who has been left out or behind have grown. This has been true especially in the wake of the pandemic. And the racial and social justice reckonings of the past three years have also boosted these calls.

It's a development we’re eager to amplify and support at Tidal Equality. 

So how can the Equity Sequence® help ensure inclusive and equitable healthcare, whether you’re a practitioner, researcher, policy-maker, or industry professional? We hope to offer some insights.

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Applying an equity and inclusion microscope

One step toward creating more inclusive healthcare is to take any healthcare-related activity and place it under an equity and inclusion microscope. To ask how well it passes an “equity test.”

If your focus is global healthcare, you’re likely concerned about health outcome disparities between wealthy vs. developing nations, or between the global North and South. The world saw these inequities when it came to COVID vaccination development and access—an issue we looked at in our blog piece, “Too Late to Vaccinate 70% of the World: What if an Equity Sequence® Mindset Had Prevailed?” which speaks to making medical care more inclusive

If your scope is domestic healthcare, you might be concerned to understand the structural barriers that prevent some groups from accessing treatment. Individuals from lower socio-economic incomes and specific racial or ethnic groups are often most at risk.

In the US, you might be concerned to unpack a statistic like this one:

“Sickle cell disease, which disproportionately affects Black Americans, is three times more prevalent than cystic fibrosis, which disproportionately affects White Americans. Yet cystic fibrosis receives about 3.5 times more funding (in federal expenditures) and 75 times more foundation funding than sickle cell disease.”

If your focus is drug development, you might ask why clinical trials (in the West) have failed to include individuals from diverse racial, gender, and age populations—and how these omissions can lead to worse outcomes for under-represented groups.

As stated in this McKinsey article, “health equity means, as a foundational matter, that everyone in a given country or region has the opportunity to be as healthy as possible, regardless of social determinants.”

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What is an example of inclusive healthcare? Increasing diversity in clinical trials

I have a personal story related to clinical trials and diversity. As an ethnic East Asian, I’m among a percentage who turn bright red when they drink alcohol. Casually known as the “Asian flush,” it means I’m a lightweight. A non-drinker—not by choice but by necessity.

But did you know there’s a wider effect beyond alcohol? 

There’s an enzyme system (Cytochrome P450). It’s involved in metabolizing alcohol, plus a long list of drugs, including anesthesia.

A 2020 study confirmed what I’ve known to grill doctors about for two decades when prescribed medication: East Asians are more often “poor metabolizers” than people of European or African descent. Many of us have a genetic mutation that results in a faulty enzyme system. 

Translated, it means certain drugs stay longer and build up in my system. My liver can’t clear them quickly enough. The result can be like an overdose.

A project to develop different protocols for East Asians requiring anesthesia was in work as of 2020. But 23 years ago, in Northern Virginia, where my mother underwent surgery for cancer, what was intended as an initial dose of anesthesia, meant to calm the system before more was administered, kept her unconscious for 48 hours.

Who knew? Not my mother’s doctors. Not then. 

Do I blame the doctors for not knowing more in 2000? How can I? The population of East Asians was still pretty low. Genetic knowledge about us as a demographic wasn’t on anyone’s radar. Most doctors weren’t aware.

But now that they are? (And if you’re a doctor and you weren’t before reading this, now you are...) What are they going to do differently? 

One answer? When designing clinical trials, make it a point to include individuals of diverse genders, ages, ethnicities, and income levels. 

Or when testing a medical device (read about pulse oximeters and skin color), stop and ask yourself: who might have been left out?

Better still, ask who else’s perspectives and experiences you might work harder to INCLUDE?

How can you make your healthcare more inclusive? Consider using Equity Sequence® in your decision-making

Equity Sequence® can help keep equity and inclusion top of mind at any healthcare decision-making juncture. We often talk about how it reduces negative outcomes by keeping cognitive biases in check.

But if you’re working to innovate in the medical and healthcare space, it can also help you find positive opportunities to promote more equitable health outcomes and advance inclusive healthcare as a goal.

The McKinsey article describes a “virtuous cycle that improves the epidemiology of care.” By nudging you to think and act equitably and collaboratively, Equity Sequence® can bolster this process, enabling each inclusive decision to compound upon itself.

Equity Sequence’s intersectional approach

As a tool, Equity Sequence® also invites you to think about the many dimensions of identity represented in your patients, target audience, and stakeholders—about their needs and perspectives. We call this an intersectional approach.

Why does this matter, ESPECIALLY for healthcare?
For one thing, there are biological and genetic determinants of health, as well as social.

Consider the earlier statistic about sickle cell disease. It’s a genetic disease, common in people of West African, South/Central American, Caribbean, Mediterranean, Indian, and Arab ancestry. Yet it’s only in a regional, social context—America—that an inequity like this becomes visible, because of research and treatment disparities for white vs. Black populations.

By asking you to consider who benefits and who is disadvantaged along multiple dimensions of identity, Equity Sequence® can help you get at nuances of who is being left out, when and where. This, in turn, can help guide you toward advancing more equitable healthcare.

Inclusive healthcare as an ethical necessity

As greater awareness of equity gaps arises, based on new data (read about the largest collection of inequality health data just published by the World Health Organization), so will ethical questions over failing to think inclusively. Because once you know, you can’t unsee. 

If you once designed clinical trials without stopping to ask whether a diverse range of participants mattered, you can’t continue to assume you have a “neutral” pool. 

Once you learn that failing to think and act inclusively could lead to adverse outcomes for whole groups of people, ignoring this amounts to an ethical failure. That’s especially true in a field meant to be guided by the principle, “First, do no harm.”

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On a final note, I admit I find it hard to talk about inclusive healthcare or healthcare equality without bringing up an elephant in the room. 

The US has chosen (so far) to reject the idea that providing healthcare to all is a basic obligation.In the US, so much healthcare inequality boils down to a seeming acceptance of extreme levels of economic inequality. Excess greed on the part of a few, and lack of power or political will on the part of the rest of us to overhaul the system, keeps too many of us trapped in a profit-based model of “care.”

That said, I recognize that even IF the US eventually adopts universal healthcare, biases and inequities will remain. And they will be perpetuated if left unaddressed. 

Canada, I’m reminded, has publicly-funded, universal healthcare. Yet during COVID, Black Canadians and Indigenous communities in Canada experienced the same types of inequities faced by Black and Native American communities in the US.

In short, regardless of system type, disparities tied to social, environmental, and other (controllable) determinants of health persist.

But this also means that, regardless of system type, there are huge opportunities to correct for inequities and to advance the goal of more inclusive healthcare. 

Equity Sequence® can be an important tool in your toolkit toward that goal. It can be the microscope you use to view any decision under an equity lens, to see how well it “passes” an equity test. As the idea of inclusive healthcare continues to grow, asking this will become an ethical necessity.

Suhlle Ahn

VP of Content and Community Relations