Communities in Action

Pathways to Health Equity

Exploring the Root Causes of Health Inequity

scroll down

Our nation’s well-being depends in part on the well-being of its communities.

     Yet many communities are facing the challenges of insufficient access to jobs, healthy food options, safe  and affordable housing, parks and open space—the needed conditions to fully thrive. This lack of equitable opportunity gives rise to the disparities that exist in health status and health outcomes between different areas of our country.

     Health equity  is when everyone has the opportunity to attain full health potential. Health inequities stem from structural inequities, the systemic disadvantage of one social group compared to other groups. Structural inequities are deeply embedded in the fabric of society, encompassing policy, law, governance, and culture.

     Health inequities are in large part a result of historic and ongoing poverty, structural racism, and discrimination. Yet these inequities can be mitigated by policies and community action in powerful ways. A report from the National Academies of Sciences, Engineering,  and Medicine offers promising approaches for promotion of health equity. What are the root causes of health inequity?

Where Does Health Inequity Come From?

Health inequity arises from root causes that could be organized in two clusters:

  1. The unequal allocation of power and resources—including goods, services, and societal attention—which manifests itself in unequal social, economic, and environmental conditions, also called the determinants of health.
  2. Structural inequities that organize the distribution of power and resources differentially across lines of race, gender, class, sexual orientation, gender expression, and other dimensions of individual and group identity.

Interventions targeting these root causes hold the greatest promise for promoting health equity.

Racism plays out at many levels.

This ecological model portrays the multiple layers of action and support needed to address health equity:

For an example of a community addressing structural racism, see Box 3-2 in the report.

What’s at Stake?

Health is shaped by more than individual choices.

  • Research shows that when it comes to important health metrics like life expectancy, one’s zip code may matter more than one’s genetic code. Where a person lives can determine up to 25 years’ difference in life expectancy from one neighborhood to the next. Life expectancy can also vary dramatically—by as much as 15 years for men and 10 years for women—depending on income level and education.
  • Infant mortality is much higher in certain populations. For instance, in 2013, the mortality rate for non-Hispanic white babies was about 5 in every 1,000. This number jumps to more than 7 in 1,000 for Native Americans and about 11 in every 1,000 for African Americans. These gaps in infant mortality are primarily attributable to racial segregation and differences in the conditions of the communities where people live.
  • The worsening opioid drug epidemic primarily affects low-income people in rural communities across the country.
  • Rates of serious conditions such as obesity, heart disease, cancer, and stroke are substantially higher in the poorest parts of the country. These disparities stem from systems and structures that make it a lot harder for poor people to live healthy lives.

So What Can Be Done to #PromoteHealthEquity?

Access to health care matters, but by itself it’s insufficient to address health disparities and improve overall health. The underlying social, economic, and environmental factors that shape health inequities need to be addressed at the local, state, and national levels.

  • Communities are taking action on the factors that shape health.
    Community assets and resources can be built, leveraged, and modified—such as building community power and nurturing the next generation of leadership—and can create a context in which to foster health equity. For examples of communities across the U.S. that are engaged in such strategies to reduce health inequities, see Chapter 5 of the report.
  • Supportive public and private policies at all levels and programs can help facilitate community action.
    Communities are more likely to thrive when there is thoughtful, evidence-informed policymaking; the political will to catalyze and sustain their efforts; evidence from data and research; and the analytical tools and resources to apply lessons from the available evidence to local conditions.
  • No one group can do it alone.
    Community-based solutions rely on multisectoral collaborations ensuring varied approaches to improving community health equity and well-being.

For more solutions to address the root causes of health inequity, see the Summary chapter of the report.

Community-driven solutions can take into account the range of factors that contribute to health inequity in the United States, such as income and wealth or employment: the social determinants of health. Chapter 5 in the Communities in Action report describes examples of communities doing just that. The determinants are the conditions in which one lives, learns, works, and plays, and they’re shaped by policies, governance, investments, culture, and norms, both historical and ongoing.

How to Start a Conversation on Race and Health
excerpted from Culture of Health Prize Winner, Everett, MA

  1. Recognize the connections among race, police practices, and health.
  2. Create a safe place for the conversation and for trust to grow.
  3. Ask and answer the tough questions.
  4. Wrap it in a larger effort to confront and change health inequities.


Health depends on much more than individual choice, which is why so many communities are engaging in the hard work of addressing the systemic root causes of health inequities. System-level changes are needed to reduce poverty, eliminate structural racism, improve income equality, increase educational opportunity, and fix the laws and policies that perpetuate structural inequities. Working to tackle unemployment, concentrated poverty, and school dropout rates can seem overwhelming to communities, but when actors in the community—residents, businesses, state and local government, and other local institutions—work together across multiple sectors, communities have the power to change the narrative and promote health equity through enduring community-driven interventions.

To learn more about the root causes of health inequity, please check out chapter 3 of the Communities in Action report.

Help Promote the Report

Pair one of the graphics below to these sample tweets. Click the graphic to download.

NASEM logo

Copyright 2017 by the National Academy of Sciences. All rights reserved