The Science of Eliminating Health Disparities

I'm checking-in at the 2012 Summit on the Science of Eliminating Health Disparities, which is focused on Building a Healthier Global Society by Integrating Science, Practice and Policy.  The summit has been rescheduled post super storm Sandy from December 17-19, 2012. 

A Broad Focus for Community: Occupy Health

Personal pursuits make a difference for health. Individuals who take responsible steps whether it’s more physical activity, smoking cessation or medical adherence face complex environmental challenges where place matters. Some face forces more formidable than will power. The research provides evidence to shed light on influences for health. A recent study published in the New England Journal of Medicine demonstrates how place matters.[1] These results show better health outcomes for those who have an opportunity to relocate to better living conditions. A move out of high level poverty areas improves the potential for health. Access to healthy food, safe spaces for play and adequate living conditions works in the fight against childhood obesity and diabetes compelling the need to broaden our focus in designing community-level interventions. There are many factors that influence health, the Commission for a Healthier America offers a view:

Influence on Health: Broadening the Focus

Influence on Health: Broadening the Focus

"Behaviors, as well as receipt of medical care, are shaped by living and working conditions,

which in turn are shaped by economic and social opportunities and resources" [2]

Consider another striking example: the climb of out of poverty, educational achievement and economic prosperity doesn’t change the high risk of preterm births and maternal death for black women. Dr. Michael Lu an obstetrician and gynecologist believes "that for many women of color, racism over a life time, not just during the nine months of pregnancy, increases the risk of preterm delivery. To improve birth outcomes, Lu argues, we must address the conditions impacting women’s health not just when they become pregnant but from childhood, adolescence and into adulthood.” The video clip is telling as is the entire documentary series “Unnatural Causes.” [3]

There are social determinants of health. We should address issues beyond the doctor’s office that impact health. Where we live, work and play influences health, medical care and health care, our environment influences our personal efforts to achieve health. [4] Our national foreclosure crisis is making people sick, physically and mentally.[5] Yes, financial ruin is about personal responsibility. However, these situations are also tied to increasing rates of unemployment and economic downturn.  It’s like thinking about how your personal spending impacts the nation’s economy without considering the roles of financial institutions and corporations.  You make the mortgage payment every month, but the equity in your house diminishes. You go to work every day, but the same paycheck buys less of everything including healthy groceries so you grab fast, cheap food. Exercise routines may compromised when you have to work a second job to meet the bills. The stress of daily living over time may become chronic stress and put your health at risk.

The low hanging fruit to address personal behaviors may heal some, but doesn’t remedy the pervasive ills facing our society. My colleagues in community development, public health and health professions are dreamers, change agents, builders, innovators, leaders and champions for health and healthier living this makes me hopeful and willing to work for progress and the future.

References

1. Ludwig J, Sanbonmatsu L, et al. Neighborhoods, obesity, and diabetes–a randomized social experiment. N Engl J Med. 2011 Oct 20;365(16):1509-19. 
2. Prepared for the Robert Wood Johnson Foundation by the Center on Social Disparities in Health at the University of California, San Francisco. 
3. Courtesy of UNNATURAL CAUSES: Is Inequality Making Us Sick? Produced by California Newsreel with Vital Pictures. Presented by the National Minority Consortia. www.unnaturalcauses.org; www.newsreel.org
4. Robert Wood Johnson Foundation Vulnerable Populations brief A New Way to Talk about the Social Determinants of Health.  July 2010
5. Robert Wood Johnson Foundation, Human Capital brief ”Foreclosure Process Takes Toll on Physical, Mental Health.” October 2011

N.B.  This post was prompted in response to Dr. Jen Gunter's blog #OccupyHealthcare post and furthers my comments.

Matters of the heart

My sketch of the human heart during first year anatomy.

She whispered to me with bulging eyes of urgency, “something is not right, I’ve been in pain all night.” Her chief complaint was chest pain.  She had a routine work-up and some care with little relief.  The news came that all of her test results were normal.  Her body appeared tense, she looked panicked and afraid.  At bedside, the attending suggested endoscopy offering that her pain may be related to a gastrointestinal condition.  I introduced myself immediately as a medical student and quickly advocated for a cardiologist consultation. I mentioned that a few months prior she had been rushed to this hospital by ambulance with what had been determined as idiopathic ventricular fibrillation. The attending shook his head, he started moving toward the nurse’s station and I followed behind.  He reviewed her case with me again and then he shouted, “endoscopy” then I said “cardiology consult.” I left quickly without waiting for a response because I was trembling with fear.

As I sat outside trying to figure what my next steps would be, my phone rang and it was the nurse, she said that the attending had agreed to the cardiology consult. I returned to our house to care for my grandmother, in the absence of my mom she had no caregiver.  In the afternoon the cardiologist called me to express his concern with mom’s condition. He recommended, pending insurance approval that she be transferred to another hospital (the one that I had told her to go in the first place) for more tests and further observation.  This hospital did not have a full cardiology service and would be closing for good within next 72 hours.

Mom was transferred that night, additional test results showed significantly block coronary arteries. Early the next morning she had cardiac catheterization to open her blocked blood vessels. After a short hospital stay in she returned home. 

For a medical student learning to observe in clinical settings is a skill that comes with practice, time as well as teaching.  Furthermore, bearing witness involves seeing the whole patient taking aim at focus beyond the chart to examine the situation. The recently released book by Dr. Augustus White, Seeing Patients: Unconscious Bias in Health Care (Harvard University Press, 2011) offers the following:

“...the race and sex of patients [influences] physicians’ decisions about whether to refer patients for catheterization...If you were black, the report (Schulman et.al) concluded, you were less likely to be referred.  If you were a woman, you were also less likely to be referred.  And if you were a black woman, you were especially less likely to be referred.”

While some have criticized Dr. Schulman’s research as “exaggerating the disparities” inequalities in treatment and care are demonstrated in his efforts providing evidence for the need to improve health care as discussed in the report  Unequal Treatment Confronting Racial and Ethnic Disparities in Healthcare by Brian Smedley et. al.  As an African American woman who is a physician-in-training, I’m glad to witness good medicine as well as mom’s progress.

Cross-posted  at KevinMD.com

A matter of healing and health: our segregation dilemma

After withstanding the longest filibuster in history, the Civil Rights Act was signed into law on May 6, 1960 paving the way for much stronger legislation includig the 1964 Civil Rights Act and the Voting Rights Act of 1965. You can see here progress as an iterative process requiring time and tenacity. Justice is slow, but steady.  The 1964 civil rights laws declared hospital segregation illegal.

Yet, the persistence of racial residential segregation continues to drive disparities in health. [1] Social factors in local settings result in variations of population health across communities. [2,3] The segregation dilemma among African Americans is distinctive because other minority groups have not lived within the historical context of the African American population, our closet kin are Native Americans. The landscape of America is changing rapidly with increasing Latin and Asian populations revealing a new story of complexity.

In growing numbers, people of different cultures and ethnic backgrounds are coexisting in communities, workplace settings, schools, playgrounds. While religious and faith centers remain some of the most segregated places in America. A few weeks ago a provocative talk considering “Race and Racism in America: Are We A Color Blind Society?” hosted by the W.K. Kellogg Foundation offered some insight into the practice of engaging into this challenging dialogue. For example, while 50% of African Americans have dated across racial lines, 98% of African Americans have experienced have first-hand experiences with discrimination. Discussions about bias, stereotyping and discriminatory practices do help to improve attitudes as well as behaviors. Silence may perpetuate pain and suffering.  Race is an illusion discounted by the the science of human biology and modern genetics, but race is a social reality. A Joint Center for Political and Economic Studies report indicates racial inequalities in health care access and quality added more than $50 billion a year to direct U.S health care costs from 2003 to 2006. In Seeing Patients: Unconscious Bias in Health Care physician-educator Augustus White offers that the Unequal Treatment report “shocked the medical world into recognition of what was going on with racial and other prejudices.” [4,5]   Deeply rooted health care disparities are entangled in the larger story in our society.  

“Housing policy is health policy. Educational policy is health policy. Antiviolence policy is health policy. Neighborhood improvement policies are health policies. Everything that we can do to improve the quality of life of individuals in our society has an impact on their health and is a health policy.”  

                                                                                   —David R. Williams, UNNATURAL CAUSES

The public conversation continues next week with a meeting offered via webcast on “America Healing” including Florence & Laura Norman Professor of Public Health, Harvard University sociologist David R. Williams. These professional meetings push beyond anecdotes so that the evidence of disparities can be seen and addressed.  In considering "What determines health?" and the social factors related to healthier lives, Robert Wood Johnson Foundation will also host a webinar on “Place and Health: Why Conditions Where We Live, Learn, Work and Play Matter” and the chat continues via Twitter hashtag #healthissocial with an expert panel.[6] These are open-door meetings, offering virtual presence attendance. We all need to consider new possibilities for healing and health in our lives.  Join the conversation.

References

1. Kramer MR, Hogue CR. Is segregation bad for your health? Epidemiol Rev 2009;31(1):178 –94. 
2. Miller DM, Pollack CE, Williams DR. Healthy homes and communities: putting the pieces together.  Am J Prev Med 2011;40(1S1):S48–S57. 
3. Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep 2001;116(5): 404 –16.
4. White AA, Chanoff D. Seeing Patients: Unconscious Bias in Health Care. Cambridge, MA: Harvard University Press, 2011.
5. Smedley B, Stith A, Nelson A, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington,DC: Institute of Medicine, The National Academies Press, 2003.
6. Lavizzo-Mourey R, Williams DR. Strong medicine for a healthier America: introduction. Am J Prev Med 2011;40(1S1):S1–S3.