NP Advocates to Know: Dr. Felesia Bowen on Health Equity

The Importance of Health Equity

“Health equity means giving people what they need so that they can live their best and healthiest life,” Dr. Bowen says. “There’s a lot that’s involved in that.”

To understand the scope of health equity, it’s helpful to consider its inverse. A 2023 report by the Kaiser Family Foundation found that Black, Hispanic, and American Indian and Alaska Native (AIAN) people all fared worse than white people across the majority of examined measures of health, healthcare, and the social determinants of health (SDOH). The reasons for those disparities are numerous, nuanced, and interconnected. Health equity seeks to untangle those contributing factors and address them intelligently. 

“Now we have all this really cool geo-coded data,” Dr. Bowen says. “You can look and see that most of the people who come to the emergency room in this city live in this zip code, for example, or that patients in this other area have a lot of hypertension.”

Many health disparities result from a sometimes purposeful uneven distribution of resources. Access to care is a multimodal question: 

• Do community members have insurance?
• Do they have reliable transport?
• Is there a clinic in the neighborhood? 
• Can they get broadband for telehealth? 
• Do they have the digital literacy to access it? 

And access to care is only one part of the equation. Safe housing, education, and nutrition are not a given in many rural and underserved areas.

“To achieve health equity, we really need to get in and assess the people and the communities that we’re working with so that we can bring appropriate services to them,” Dr. Bowen says. “There are a lot of resources that people need. It’s not enough to offer food stamps or SNAP aid; we’re not just talking about food, but nutrition.”

The more one tugs at the thread of health equity, the more that seems to come unraveled. Even in areas with clinics and transport, the quality of care or the hours of operation may exclude a significant and vulnerable element of the population. The problem is sticky, and reflexive: even as individual barriers get removed, those who need resources the most often remain the ones with the most difficulty obtaining them. But nurses and NPs, with their holistic approach and focus on the social determinants of health, can make a crucial difference.

One Advocate’s Journey

Dr. Bowen’s nursing journey started in the 1980s at Alabama Tuskegee University—an HBCU located in what’s known as the Black Belt, a region nicknamed for its dark, rich soil. During a community health rotation in her junior year, Dr. Bowen found that many of the people in the area lived in abject poverty: healthcare, housing, and running water were not a given. As an Army brat, whose family had earned the right to access the universal healthcare system of the armed forces, the contrast was eye-opening.

“Some people can’t just go to a doctor whenever they need to,” Dr. Bowen says. “I’d grown up in a system where that was always provided.”

After university, Dr. Bowen joined the military herself, serving in the first Persian Gulf War. Deployed to Saudi Arabia, she again observed the stark contrast between the haves and have-nots: the wealthy beneficiaries of the Saudi petrostate set against the tribal Bedouin people. It was also in the military where Dr. Bowen learned about the nurse practitioner role and chose to go to graduate school and pursue the path to becoming a pediatric NP. 

“For me, working with children and their families and communities represents the ultimate level of disease prevention and health promotion,” Dr. Bowen says. “Because you don’t just wake up at 40 with high blood pressure. If we can give kids a good head start and set them up so their lifestyle is healthy, they’re so much better off.”

After graduate school, Dr. Bowen began practicing in Federally Qualified Health Centers (FQHCs)—sometimes referred to as safety net clinics—where she could be in the local community, providing care to those who wouldn’t otherwise be able to access or afford it. Working in rural and underserved areas reconnected Dr. Bowen with what she’d seen in the Black Belt. It illuminated several striking health disparities, some of which she went on to document and investigate while earning a PhD in nursing science.

“I was seeing kids with asthma who were not getting better,” Dr. Bowen said. “So my dissertation was on pediatric asthma. And I learned that asthma is extremely complex. Some of these kids had access to medication and Medicaid, but their family structures complicated it: mothers couldn’t take time off work to take their kids to the doctor.”

This dissertation brought Dr. Bowen firmly into the world of health equity, where the logistics of time and transportation are merely two variables in a much wider spectrum of uneven circumstances that disproportionately affect the ability of individuals and communities to access care. And, as professor and associate dean for DEI at the University of Alabama at Birmingham School of Nursing, she works to bring more nurses and nurse practitioners into the cause, too.

How NPs Can Help Build Health Equity

An optimistic way of looking at the issue of health equity is that all the obstacles that stand in its path also provide vectors for meaningful intervention. More simply, every barrier is an opportunity. Small, individual actions can have a big difference. For nurses and NPs, it starts with treating patients holistically and with compassion. A single question can unlock a patient’s circumstances, family, and community. Starting small initiatives at the clinic and neighborhood level and championing the initiatives of others has force-multiplying effects. 

“Even though it can seem daunting, there is optimism,” Dr. Bowen says. “There really is. That’s where I get my energy from.”

But treating the symptoms of inequity is not enough. The root causes are structural. Many policies have shown cruel indifference to the disparities in where voting lines are drawn, how school budgets are allocated, and who gets access to what resources. At times, that cruel indifference has actually been a more purposeful evil, creating pockets of poverty and inequality that persist to this day. Dr. Bowen says the most impactful way to undo those policies is by registering to vote. 

“We’re talking about structural racism,” Dr. Bowen says. “There are layers and layers of federal and state policy that were put in place to keep people down. We need to acknowledge that it exists and what it perpetuates, so we can be thoughtful about how to change it.”

Nurses and NPs can also help educate legislators, most of whom do not have a healthcare or public health background, about the upstream and downstream effects of new and old policies, even policies that don’t deal with healthcare directly. At the same time, NPs also need to educate themselves about the policies already in place and the mechanics of how those policies can be changed. 

“Nurses have to educate themselves,” Dr. Bowen says. “I can’t tell you how many times I’ve heard nurses say, ‘Why do I need policy? I don’t want to be political.’ But there’s politics in everything. Your voice is your vote.”

The Future of Health Equity

Health equity is inextricable from the social determinants of health. Its principles of treating the whole patient and their unique context will continue to be threaded through nursing curriculums. 

But Dr. Bowen is hopeful that in the future, nursing will see a growing diversity of providers and leadership voices who can better match the diverse tapestry of the American population. This isn’t just about racial or ethnic backgrounds but about a wide spectrum of different perspectives. 

“One of the beautiful things about higher education is that for so many people, it’s the first time they’re ever exposed to people and cultures and thoughts that are not their own—that are unlike what they grew up around,” Dr. Bowen says. “If you don’t have an opportunity to hear a different perspective, then how can you begin to shape your own?”

In 2024, some of the elements of healthy equity are under attack, and, ironically, nowhere more so than in Southern states where many of the nation’s health disparities are the most severe. The madness of the controversy can sometimes obscure health equity’s inarguable point: everyone should have the opportunity to lead a healthy life, and everyone can. This is not a zero-sum game.

“I could spend a lot of time trying to convince the naysayers why they should be doing this,” Dr. Bowen says. “What I’ve done instead is to find people from all different backgrounds and races and religions who are hopeful, who are excited, and who are willing to say we need to make a difference here. And we’re coming together and we’re having conversations about how we can do that, starting at the neighborhood level. We need to have combined solutions. That’s how we’re going to fix this.”