Last week, the American Medical Association (AMA) brought together experts to discuss issues of data and measurement in the latest edition of their National Health Equity Grand Rounds series. 

Event panelists included Lown Institute President Dr. Vikas Saini, Dr. Elena Mendez-Escobar (Boston Medical Center), Linda Villarosa (journalist, educator, and contributing writer to the New York Times Magazine), and Dr. Ryan Petteway (OHSU-PSU School of Public Health). 

“What [data] can do is create additional vehicles for people who want change…to take on the challenge of structural racism in the country.”

-Dr. Vikas Saini

The panelists tackled some of the most pressing questions related to data, metrics, and the path forward for equity in medicine, such as:

• How can we leverage data to better understand the experiences and outcomes of all patients?
• What does it look like to measure what matters?
• How can we move from research to action?
• How do we make sense of data overload in the 21st century?
• What should medical students and young health care professionals know about the future of equity in medicine?

“We view this as a time for a new paradigm [in healthcare]…the key issues are equity, accountability, and the value of care.”

– Dr. Vikas Saini

The post WATCH: The data we need for more equitable care appeared first on Lown Institute.

What does affirmative action have to do with healthcare? The Court’s 6-3 decision will have a drastic impact on the diversity of incoming medical school classes and our medical workforce in the coming years. We know from previous research that state bans on affirmative action lead to reduced enrollment from underrepresented groups in medicine. A UCLA study comparing enrollment in states with and without affirmative action bans found the proportion of underrepresented groups dropped by more than one-third over 5 years. 

Why does this matter?

Despite advanced technology, wealth, and a brilliant medical workforce, American public health statistics have not looked great lately. Life expectancy is going down, maternal and child mortality are going up, and chronic disease is on the rise. But not all Americans are affected equally. Non-white, specifically Black Americans, fare worse across numerous measures of health. 

“Time after time, studies have shown that class is not protective. Social status is not protective. And in the experience of our fellow physicians, even being a doctor cannot save you from racism in medicine.”

– Jessica Faiz, Utibe R. Essein, and Donna L. Washington in STAT News

Physician diversity is one powerful way to counteract these negative trends. A JAMA Network Open study from April looked at Black primary care physician representation in 1618 counties over a decade and found that more Black physicians corresponded to lower mortality rates and reduced mortality rate disparities. Other research has suggested that having a doctor of the same race improves communication, trust, and outcomes, particularly for Black men. However, less than 6% of physicians are Black, less than 7% are Hispanic, less than 0.5% are Native, and progress has been slow. 

Black physicians have also been the ones to push for needed change in how we approach medicine. Dermatology suffers from a lack of training on dark skin, so a Black medical student created a textbook to address the problem. Nephrology is trying to fix a faulty algorithm that has been keeping Black Americans off the kidney transplant list. Oncologists have been working on addressing higher rates of breast cancer mortality in Black Americans for years.

Simply put, more Black physicians means better health outcomes for Black Americans. The Supreme Court’s decision will have negative population health consequences in the coming years. Institutions of higher education will have to be creative to counteract this step backward.

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2 Miles, 23 Year Life Expectancy Difference

In Boston, the two-mile difference between the Roxbury area and the Back Bay area could make the difference of 23 years in terms of life expectancy. This stat comes from a recent analysis by the Boston Public Health Commission, which also identified stark differences in income, education, race, and rates of homeownership between the two neighborhoods. The combination of these social determinants likely plays a major role in the life expectancy gap.

Boston is not the only city with significant differences in neighborhood life expectancy. Chicago, Los Angeles, Houston, and many other cities have documented persistent life expectancy disparities by neighborhood, also closely tied to the social determinants of each neighborhood. 

Our data at the Lown Institute shows that many hospital markets are racially segregated, further contributing to the varying health outcomes between one group of residents vs another. In some cities, prestigious academic medical centers underserving patients from low-income communities and communities of color, while safety nets disproportionately serve these patients. In New York City, for example, a New York Times investigation found that wealth undeniably affords faster, better treatment. VIPs at NYU Langone were given priority access and special treatment, while poorer patients were directed to go to the public safety net hospital.

The accumulation of a lifetime of disparities

The fact that these social determinants are cutting years off residents’ lives is not new. In 2012, a similar study by the Center on Human Needs at Virgina Commonwealth University identified a 33-year life expectancy gap in Boston. The gap has decreased by 10 years over the past decade–but why does this gap persist at all?

The Associated Press published a series of articles investigating the lifetime of disparities faced by Black Americans, covering the impacts of racism from pregnancy to childhood through old age. Every step along the way, Black Americans faced worse health outcomes. The accumulation of a lifetime of disparities results in “weathering,” a term used to describe the physical impacts of chronic stress. Over years and years, “weathering” diminishes health outcomes, increases the rate of chronic health conditions, and ultimately cuts lives short. According to a recent JAMA study, racial inequities are related to an excess of 1.63 million deaths over two decades.

There are numerous ways in which social determinants impact life expectancy, and just as many potential solutions. From eliminating toxic environmental exposures and expanding healthcare access to making neighborhoods greener and investing in education, we have plenty of options to mitigate the negative impacts of social determinants of health. Hospitals can play their part by focusing on their community members in need, rather than on recruiting wealthy patients for elective, albeit profitable, procedures. Our data shows some hospitals are already prioritizing inclusivity, but we need more to follow their lead. The slow pandemic of weathering is ongoing, but it doesn’t have to be this way.

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There are a plethora of impressive Black clinicians in American history, from Dr. Rebecca Lee Crumpler, the first Black woman to earn a medical degree, to Dr. Jane Cooke Wright, whose research on cancer treatment laid the foundations for chemotherapy to become a viable option for patients. One that we’d like to highlight is Dr. Charles Drew. 

Prior to the mid-twentieth century, blood donations were separated into “white” and “black.” This racist system meant that white people would only take “white” blood for transfusions, despite no scientific basis for the labeling. At the time, no method had been developed to properly store blood donations, leading to unnecessary suffering. Dr. Charles Drew was one of the brilliant scientists who pioneered the procedures for the preservation of blood plasma in 1939, earning him the title “Father of the Blood Bank.” Later, he created refrigerated blood donation trucks known as “bloodmobiles.” His innovations revolutionized medicine and saved countless lives.

Ironically, because of his race, Dr. Drew was unable to participate in the very programs he created. He was an outspoken critic of blood segregation, and at one point said, “It is unfortunate that such a worthwhile and scientific bit of work should have been hampered by such stupidity.” Dr. Drew went on to train up-and-coming Black surgeons at Howard University for nearly a decade before tragically passing away in a car accident in 1950. At the time of his death, his advocacy efforts had gained momentum and blood banks began desegregating their blood across the country–although it took until the 70s for the final state to get rid of their racist policies.

“It is unfortunate that such a worthwhile and scientific bit of work should have been hampered by such stupidity.”

-Dr. Charles Drew

Dr. Drew was not alone in fighting for equality in blood donations. Lown Institute founder Dr. Bernard Lown was expelled from medical school for his antiracist activism while working at the blood bank. He sabotaged the segregated blood bank by re-labeling “Black” blood as “white”, undermining the system with a single black crayon.

Dr. Drew and Dr. Lown’s advocacy efforts took years to see success. Fully desegregating blood donations has been a goal for decades. Even today, the goal of equity in blood donations has not been fully reached. As recently as 2006, Black communities were subject to an experimental “blood substitute” without informed consent. And just last month, the FDA moved to finally allow gay men to donate blood, under certain stipulations. Advocacy for an equitable and just healthcare system continues.

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The dark origins of obstetrics and gynecology

James Marion Sims was one the most famous surgeons of the 19th century and is recognized as the father of modern gynecology. He pioneered the technique to fix vesicovaginal fistulas, which were a common and severe complication of pregnancy at the time. He invented the modern speculum and the Sims position for examinations. In 1855 he founded the Women’s Hospital, the first hospital for women in the United States. 

He practiced and developed these techniques on enslaved women. 

The women Sims’ experimented on were never given anesthetics, which were in fact available. As a slaveowner himself, he understood the capital generated by enslaved workers as well as the financial benefits of high rates of reproduction. For many years, his experiments were unsuccessful and his patients went through agony. Once he perfected his techniques, he took them to white women experiencing gynecological problems–alongside anesthetics.

Today, Sims has a complicated legacy. Monuments to him stand tall across the country, though some are beginning to come down after public outcry. As the medical field grapples with the exploitative nature of the emergence of gynecology, it must also reckon with the consequences of structural racism still present in the modern-day system.

Black moms matter

The United States has a maternal mortality crisis, and its compounded by systemic racism. The CDC estimates that 80% of pregnancy-related deaths are preventable, and Black women die due to pregnancy-related complications at over 3 times the rate of white women. Neither education, income, nor fame are guaranteed to be protective factors, as evidenced by the tragic cases of Dr. Chaniece Wallace and Shalon Irving, as well as Serena Williams’ harrowing near-death experience. A new study from the National Bureau of Economic Research was featured in the New York Times for its findings that regardless of income, outcomes for both Black moms and their babies tend to be far worse than for other racial and ethnic groups.

But on a positive note, more Americans are becoming aware of the Black maternal mortality crisis, and policymakers are taking action. The Black Maternal Health Caucus, led by Representative Lauren Underwood, introduced the Momnibus Act to address these challenges. The Momnibus includes 12 bills all aimed at reducing Black maternal mortality. Some of those provisions have been signed into law.

Communities are stepping up to protect Black maternal and infant health as well. By advocating for non-traditional supports such as birth centers, doulas, and more Black healthcare providers, which are all associated with better health outcomes for Black women and their babies, community members are showing up and supporting a better future. In Minneapolis, a brand new birth center opened up and was named as Dr. Uché Blackstock’s bright spot of the year during the 2022 Shkreli Awards. Another community in Colorado rallied to save a birth center after a private equity firm shut it down. The movement to include Medicaid coverage for doulas is building momentum, following the success of the movement to extend Medicaid coverage for postpartum care. Community action and advocacy are working. 

The history of obstetrics and gynecology is a dark one, and racial inequities remain persistent. But progress is possible and we need to demonstrate that our Black moms and babies matter.

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This past January, Florida’s department of education rejected course materials and topics for a new AP African American Studies course, writing to the College Board that the subject matter “significantly lacks educational value.” This has concerning implications for the next generation’s understanding of the world around them – and how they conceptualize the impacts of social determinants of health, bioethics, and the history of this country.

Black History and Health

Why is learning Black history in the US necessary for our nation’s health? Closing racial health gaps is a key concern, but we don’t give our health professionals the historical context they need to do the best job of closing these gaps. Myths about physiological differences based on race (such as Black people feel less pain or have worse lung function) were created centuries ago to justify slavery and discrimination. But some of these myths are still present in the medical community, furthering unequal care. 

The de facto segregation in hospitals also needs a historical context to be understood and dismantled by medical educators, clinicians, and hospital leaders alike. In the AMA Journal of Ethics, Dr. Emily Cleveland Manchanda and colleagues explain how current segregation in medicine stems from our history of racist policies like redlining, exclusionary zoning, and the bifurcation of publicly and privately insured patients. Without knowing the history, Manchanda et al. write, it’s easy for the medical system to assume that segregation is normal, and to keep the cycle going.

And as medical schools strive to include more students from underrepresented backgrounds, we need to have an understanding of the policies that led to the closure of most Black medical schools in the 1900s.  

Queer Studies and Intersectionality are also Black History

Two of the target topics rejected by the Florida Department of Education were queer studies and intersectionality. “Intersectionality” was coined by Kimberlé Crenshaw over 30 years ago as a way to conceptualize and describe the various ways a person’s social identities, like race, gender, and class, overlap. Examining the world through this lens allows for a more complete, nuanced understanding of how these determinants play out in a person’s life. By cutting the reading requirements of queer and feminist scholars, this move is an attempt to sever the connection between queer studies, intersectionality, and Black history. But these are not, and never have been, fully separate topics.

Consider the gay rights movement, for example. The Stonewall Riots are largely seen as the catalyst for the movement. The most prominent figure and activist from the Stonewall Riots is Marsha P. Johnson, a Black gay and transgender rights advocate who herself had experienced the impacts of intersectional marginalization. She was on the front lines of the Riots, galvanizing a nationwide fight for equality. 

Discrimination, especially as experienced by Black trans and gender non-conforming individuals, has an impact on both short- and long-term health. A well-known example is the AIDS crisis, in which homophobia both from the government and community members isolated LGBTQ+ individuals and treated them as disease vectors, not people. Activists have fought the dual damage of racism and homophobia for decades. Even today, Black Americans count for 40% of the 1.2 million Americans living with HIV despite only constituting 12% of the nationwide population.

The impacts of intersectional marginalization are still obvious in our society today. There is an ongoing public health crisis of violence against Black transgender and gender non-conforming individuals. It is impossible to conceptualize this crisis without having a foundational understanding of the history of harm these groups have endured.

There is no understanding the gay rights movement without understanding the intersection of race, sexuality, and gender, and how that affected individuals’ lived experiences. To exclude even one is to have only partial comprehension.

Looking at our healthcare system, it’s easy to see how racism is baked into the structures and policies to create disparate outcomes. Acknowledging the systemic nature of racism is the first step toward reaching the equitable system of health we all want and need — we should embrace it, not fear it.

The post The Intersection of Black History, Queer Studies, and Medicine appeared first on Lown Institute.

Racism and Kidney Transplants

Black Americans are nearly four times as likely as white Americans to develop kidney failure. Theories for why include higher rates of hypertension, diabetes, and diminished access to healthcare. In other words, it’s believed to be the long-term effects of weathering structural racism. 

However, racism embedded within our medical system, through practices like race-based algorithms, also lead to disparities in treatment. An algorithm is a tool used by doctors to help them decide which treatment is right for patients based on their health conditions and other characteristics. The algorithm that determines when and where someone makes it onto the kidney transplant list is based on the assumption that Black Americans have higher baseline creatinine levels, making it appear that their kidneys are functioning better than they actually are.  The algorithm is so flawed that the Organ Procurement and Transplantation Network board unanimously approved dropping it last summer. Some hospitals, like the University of Maryland Medical Center, are ending the use of the algorithm in efforts to improve health equity.

“For a number of years, some eGFR calculations have included a modifier for patients identified as Black. This practice has led to a systemic underestimation of kidney disease severity for many Black patients.“

-Organ Procurement and Transplantation Network, June 2022

Restoring Justice in Nephrology

Eliminating the faulty algorithm was step one in restoring equity and justice to kidney medicine. This past month, the Board of Directors of the Organ Procurement and Transplantation Network approved a waiting-time adjustment to retroactively fix previously calculated qualifying dates for Black kidney candidates. The board also set a one-year deadline, indicating their interest in immediate action.

Keeping the momentum going

Outdated race-based algorithms like the one used for kidney transplants are still being used within medicine, impacting Black Americans across the country and diminishing the quality and timeliness of care they receive. In dermatology, the lack of dark-skinned representation in training and materials has resulted in missed diagnoses of conditions like melanoma. In cardiology, race as a factor in the Heart Failure Risk Score can affect recommendations for admission. Obstetrics recently abandoned race-based algorithms that resulted in Black women being told they were less likely to successfully deliver vaginally after previous cesarean sections.

New calculations will be needed to equitably rate risk and determine the best course of healthcare action. We need some way to incorporate the adverse health impacts of structural racism and the effects of shifting social determinants of health while maintaining equity for all. There are plenty of places to start. 

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