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CDC Encourages Inclusive Communication to Foster Healthcare Equity

Many inequities are entrenched in our society.

What we say and how we say things matters. Many inequities are entrenched in our society, and in the way we communicate. I have talked about this topic previously, and I am still personally learning and growing. I read a piece in Medscape the other day that drew my attention, titled “How and Why the Language of Medicine Must Change.”

It was referencing the Centers for Disease Control and Preventions’ (CDC’s) Health Equity Guiding Principles for Inclusive Communication. The CDC is encouraging public health professionals and partners to apply these principles in their information resources, presentations, when developing or reviewing external or internal materials, or when communicating with others. I will reflect here what I have gleaned from these guiding principles.

Longstanding, systemic social and health inequities have been introduced, exacerbated, or perpetuated by policies in the past, and this has resulted in profound impact on populations. Specific actions, like failing to acknowledge the existence of the disparities, or using certain terminology, perpetuate these inequities.

Concepts offered by the CDC include:

  • Racism and other types of discrimination disadvantage people, and can lead to social and health inequities;
  • Ensuring everyone has an equal opportunity for health benefits throughout society in general is vital;
  • Access to information is not sufficient if the intended recipients cannot assimilate the information; they need to have it presented in a culturally and linguistically appropriate fashion;
  • Inadequate resources or infrastructure can prevent populations from following public health recommendations;
  • Community engagement and collaboration are critical to successful programs and outcomes; and
  • Literacy and digital access must be considered for effective messaging.

There are terms I used to think were meaningful and acceptable, which this information debunks. Adjectives such as “vulnerable,” “marginalized,” “high-risk,” “underprivileged,” or “underserved” can imply that the condition is inherent to the group, as opposed to being inflicted on them. Previously, I had an epiphany when I first heard a member of the media flip the word “slave” to “enslaved person.” It is the same concept, which is contrary to the typical language-arts approach of using active as opposed to passive verbs.

There are numerous examples in the communication guide. Instead of saying “marginalized group,” they recommend documenting “group that has been economically marginalized.” Groups are “placed at increased risk due to (x)” as opposed to being a “high-risk group.”

They recommend using person-first language, instead of dehumanizing language. Humanize them by referring to them as “people” or “persons.” “Diabetics” become “patients with diabetes;” “the homeless” become “people who are experiencing homelessness.” This practice prevents us from identifying people by a single facet of their circumstances, e.g., disability, incarceration, or disease process. Subpopulations are heterologous, and including as much specificity as you can is recommended. For instance, instead of saying “minority,” you might consider “people from (racial or ethnic) minority group,” or replacing “disabled” with “people living with cognitive disabilities.”

A big eye-opener for me has been avoidance of words with potentially violent connotations. Words like “target,” “tackle,” “combat,” “fight,” or “war” against should be substituted with “engage/prioritize/collaborate with/serve (population of focus)” or “eliminate (issue/disease).”

The guidance recommends avoiding unintentional blaming, and suggests considering whether language could lead to negative assumptions, stereotyping, stigmatizing, or blame, although it concedes that some such terms may be appropriate in some instances. We could consider not jumping to the conclusion that someone is choosing to not participate in a public health behavior or accessing a service by choice; yet it is conceivable that access or other structural issues may be playing a role. Has the patient refused a vaccination, or have they not received a vaccination yet?

There is a whole set of preferred terms that, again, shifts towards non-stigmatizing language. It is not splitting hairs; being formerly incarcerated or being under the custody of a government agency should not define a human being. It is just a single aspect of their complex life. I recommend that you read through the suggestions.

My interpretation is that a best practice is to start the phrase off with “person/people” and then describe what they are afflicted with or what misfortune they are experiencing, as opposed to making it an adjectival descriptor. I could envision having to read this section over multiple times to absorb all of the advice – it is expansive, and might take a while to integrate it. In practice, this also may result in some swelling of the medical record.

When depicting graphically, there are recommendations to avoid using stereotypical dress or gender. Caricatures should be avoided. Inclusion of persons with visible disabilities or from varying racial/ethnic groups is endorsed. Having a native speaker or a person from the culture intended as the audience reviews materials is advised, to ensure there are no faux pas.

I would like to add that I am afraid we are not always going to be perfect at this. If someone has been using certain phraseology for 60 years, they may not be able to choose best-practice verbiage every time from the onset.

We must aspire to be inclusive and treat everyone with respect and dignity, and keep at it until we can get it right every time – by which time society hopefully has eliminated healthcare and social disparities.

Health Equity Guiding Principles for Inclusive Communication | Gateway to Health Communication | CDC, Centers for Disease Control and Prevention, accessed online April 4, 2022.

Programming Note: Listen to Dr. Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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