Low-value care and equity

Given the health risks of overuse, it’s important to understand the impact of low-value care on health equity. Are people of color at higher risk of overuse than white patients, or vice versa? The evidence on this so far is mixed. A systematic review of studies looking at low-value care by race found that white patients were more likely to receive unnecessary care, but another more recent study found higher rates of overuse for certain low-value services in Black and Hispanic patients, such as feeding tubes for dementia. Clearly, there is a lot more to be studied on this issue.

Cue a new analysis from Harvard Medical School professor Dr. Ishani Ganguli and colleagues in The BMJ. This study looked at rates of 40 low-value services in nearly 10 million Medicare patients across 595 health systems. Ganguli and colleagues compared the likelihood of receiving low-value care between Black and white Medicare patients, including a comparison of patients within the same health system. Low-value services measured included screening tests, diagnostic tests, monitoring tests, drugs, and procedures.

Here are key takeaways from their study:

• There were significantly different rates of low-value care for 29 of the 40 services measured, although most of the differences were small. Black patients had higher rates of nine low value services and white patients had higher rates of 20 low-value services. 
• White Medicare patients were more likely to receive low-value screening tests such as prostate-specific antigen testing in men over 75 (31% v 26%) and cardiac screening (5% v 2%), as well as treatments such as antibiotics for cold or ear infection (37% v 33%), and vertebroplasty (5% v 3%) which is an injection of cement into the backbone.
• Black Medicare patients were more likely to receive feeding tubes for advanced dementia (9% v 2%), two or more concurrent antipsychotic medications (8% v 5%), and certain low-value acute diagnostic tests, like imaging for uncomplicated headache (7% v 3%).
• Differences in low-value care remained even when comparing patients within the same health system. That’s important, because it indicates differences in the way patients of different races are treated by the same providers–rather than just differences in culture between the health providers they frequent. 

Drivers of disparities in low-value care

What could explain these differences? The study authors suggest some potential reasons why Black patients could be more likely to receive low-value diagnostic tests:

“Mistrust in the healthcare system because of historical and present day racism might contribute to Black adults being more receptive to diagnostic testing when acutely ill—in this scenario, it is possible that a tangible test is more reassuring than a clinician’s words and might serve to lessen valid concerns about undertreatment.”

The authors also point out that structural barriers to care for Black patients can make it hard to access care earlier and result in them arriving to the ER sicker, which could prompt low-value testing. Additionally, if patients are more likely to seek care in the ER or urgent care as opposed to primary care, they may be subject to more low-value testing from doctors who don’t know them well. Why does this matter? Low-value diagnostic testing exposes patients to radiation exposure, out-of-pocket spending, and additional follow-up testing and procedures (known as “care cascades”).

Black patients were also more likely to receive feeding tubes in the setting of advanced dementia, a practice that does not help patients live longer, and is not recommended for these patients. Differences in rates of feeding tube usage may reflect lack of trust and communication between clinicians and patients; one study found that 14% of family members of patients with feeding tubes reported that there was no discussion about feeding tube insertion, and 42% reported a discussion that was shorter than 15 minutes.  

On the flip side, why are white patients more likely to receive certain low-value screenings and treatments? The authors suggest that white patients could be more likely to request these services, or clinicians might be more likely to offer them, perhaps because of implicit biases. Black patients are less likely than white patients to receive certain cancer screenings that are considered high-value, such as age-appropriate colonoscopies and mammograms, so it makes sense that they are also less likely to receive low-value ones. 

This study provides valuable information on the intersections between health equity and value, but there’s still much more to learn. The authors suggest that health systems measure use of low-value services stratified by racial group and sex, to identify potential disparities. “These results invite further exploration of differential access by race to routine, high value primary care, patient-clinician concordance, and trust,” they write.

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Artificial intelligence (AI) has become a key tool for industries to boost productivity and reduce administrative burdens. As health equity has become a central focus for hospitals and other healthcare institutions, how could AI help – or hinder – these efforts?

What is AI?

At its core, AI operates in a similar way as humans. Just as we read and consume information, pick up patterns, learn from experience, and solve problems, computers can mimic these behaviors. If you’ve ever communicated with a chatbot, talked to a Siri or Alexa, or used autocorrect and other text editors, you’ve made use of artificial intelligence.

Some AI programs are programmed to have pre-determined rules and outcomes (traditional, or rule-based AI). For example, a rule-based AI could be a program that flags certain patients, based on pre-prescribed symptoms and risk factors present in their medical record.

Other AI programs are provided with large amounts of data to “train” the computer, allowing it to develop a knowledge base that can evolve and expand as it is introduced to more information. When posed with questions or requests, AI systems comb through their knowledge base to search, synthesize, and report information. These are known as data-based, or machine-learning algorithms. Some programs use both approaches together.

How healthcare systems are using AI

Much of healthcare’s use of AI has focused on record-keeping, clinical research, and patient diagnoses and linkages to care. Leveraging AI has allowed medical providers to create individualized treatment plans, predict and map epidemics, flag certain patients for high risk of COVID-19 complications, and take notes during visits automatically.

For example, Microsoft and Epic – the electronic health record (EHR) platform – have partnered to use AI to streamline clinical summarization and documentation efforts. The Mayo Clinic will utilize a Google cloud generative AI tool to provide staff with immediate and expansive access to clinical information and research. And on the health equity front, companies are popping up to promote AI tools that identify and measure health disparities and track progress on health equity metrics.

Efficiency versus accuracy

Although AI has great potential, these programs have been criticized for exacerbating structural and systemic inequities. AI algorithms are generated within the confines of structural inequities that devalue communities based on aspects of their identities, including race, ethnicity, gender, sex, etc. AI’s knowledge base is then infused with these biases. 

Here’s a real-world example of how that happens: Health systems were using an algorithm to predict which patients had the greatest health needs. The model used healthcare spending as a proxy for illness, under the assumption that patients with the highest healthcare utilization had the greatest need. Researchers later found that there was substantial bias in the model – because Black patients were less likely to be able to access care (even when they needed it), they were deemed to have lower health needs. As a result, these patients were getting overlooked, with only 18% receiving additional help when 47% needed it. 

This is not an isolated incident. AI has proven far more successful in diagnosing cystic fibrosis than sickle cell disease, a health condition that disproportionately affects Black communities and suffers from an overall lack of research, despite the conditions’ similar genetic nature and severity. A study of AI diagnostic algorithms for chest radiography found that underserved populations (which are less represented in the data used to train the AI) were less likely to be diagnosed using the AI tool. Researchers at Emory University also found that AI can detect patient race from medical imaging, which has the “potential for reinforcing race-based disparities in the quality of care patients receive,” according to Emory radiologist Judy Gichoya.

Technology with accountability

Having identified the ways AI can reinforce inequities, we must prioritize the strategic use of AI. Organizations and researchers alike have taken steps to hold technology accountable and ensure AI is used ethically. Here’s what some of our hospital systems and policymakers are doing now:

• Last year, the FDA released guidance stating that certain AI tools should be regulated as medical devices. The FDA is also working on finalizing more rules around the security, quality, and validation of AI models.
• NorthShore – Edward-Elmhurst Health and AVIA are working together to develop a generative AI plan for healthcare systems that focuses on the risks and opportunities of AI as well as guidelines to monitor their usage and effects.
• Hospital systems like CommonSpirit and Penn Medicine are collaborating with health systems and other organizations to screen for, identify, and eliminate biases within EHRs. 
• The National Institutes of Health launched the All of Us Research Program to collect data from at least one million U.S. citizens to generate one of the largest and most diverse medical datasets.

Moving forward, here are some strategies that organizations can use to prevent AI from driving more disparities:

Education

• Educating the public and healthcare professionals on AI in terms of what it is, how it’s used, and its implications on care provision.
• Generating awareness of the data that is being used in terms of who it was collected by, how the information was gathered, and the population in which the data represents.

Regulation

• Creating equity criteria to evaluate and screen algorithms for the presence of inequity.
• Requiring more information from companies developing AI on the demographics of the datasets used
• Forming regulatory bodies and standards for AI generation and usage.

Research

• Collecting and using diverse data to create accurate views of disease and mortality across racial and ethnic groups.
• Accounting for genetic diversity in datasets to ensure effective precision medical treatments.

As we continue to leverage AI as a tool of efficiency and productivity, we must be intentional about its use and anticipate the impact it will have on society. It’s time that the healthcare system at large takes the necessary steps to use the power of AI for good.

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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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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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For example, the New York Times recently reported that NYU Langone Hospitals pressured emergency department doctors to prioritize “VIPs” for treatment, while shuttling poor and homeless patients to Bellevue, a public hospital with fewer resources.

The pattern of segregation–driven by redlining and other housing policies, unequal hospital reimbursements, and bias in medical culture–is deeply rooted in our healthcare system. But there are ways that clinicians, hospital leaders, medical educators, and policymakers can take action to make healthcare more equitable. A new series of articles on healthcare segregation in the American Medical Association’s Journal of Medical Ethics provides a call to action and a way forward for all actors in the healthcare system looking to improve racial and economic equity.

Why desegregation matters

Healthcare segregation means that people of color are often concentrated in certain hospitals, usually public or safety net hospitals (hospitals with the mission to provide health for everyone, regardless of their ability to pay), while elite academic medical centers are often out of reach. 

This leads to disparities in access and quality of care. For example, Black and Indigenous individuals are deeply underrepresented in clinical trials of new cancer drugs, in part because they have less access to the hospitals that run these studies. Lower-quality care at some safety net hospitals also contributes to higher rates of COVID-19 mortality and life-threatening birth complications for Black people. 

The role of medical education

In the AMA Journal of Medical Ethics, Lown Institute president Dr. Vikas Saini along with AMA health equity leaders discuss how medical education contributes to healthcare segregation and how academic medicine can promote anti-racism. The authors point out that many academic health systems disproportionately funnel Black, Latinx, and Indigenous patients and low-income white patients into safety net centers and resident clinics, while keeping faculty-only clinics within the same system exclusive.

Medical education itself also fails to teach students about structural racism in our society that created and perpetuates segregation–in part because people of color, particularly Black and Indigenous physicians, have been systematically excluded from leadership roles in medical education, the authors write.

How can medical educators begin to fix healthcare segregation? They can start by learning about the issue, listening to others, and acknowledging structural inequities with students when they occur. Academic medical centers should adopt curricula that address the structural racism and other systems of power and oppression (many residency programs are already doing this). Finally, leaders of academic medical centers must address segregation of employees within the hospital itself by hiring and retaining diverse faculty, committing to paying a living wage to all employees and contractors, and creating new career development pathways for low-wage hospital workers.

Payment reform

However, it will take more than actions from individual academic medical centers to desegregate hospitals. That’s because the incentives to treat patients differently based on their race or income is embedded within the healthcare payment system.

Hospitals get paid the most to perform high-tech elective surgeries for patients with private insurance but barely break even on preventive or routine care for patients with Medicare or Medicaid. This means their financial success often depends on attracting wealthier patients with private insurance, patients who are more likely to be white.

In another article in the AMA series, Kimberly A. Singletary and Marshall H. Chin at UChicago Medicine provide recommendations for antiracist payment reform. The two main policy changes they suggest are around healthcare coverage and quality improvement. Ideally we would eliminate our 2-tiered healthcare system and ensure access to quality health insurance for all. Smaller steps include providing more incentives for hospitals to care for patients with Medicaid or uninsured patients, increasing insurance coverage for interventions that address patients’ social needs,

To improve equity in health quality and outcomes through payment, the authors recommend:

• requiring Medicaid managed care plans to implement racial equity impact assessments and other antiracism measures,
• boosting payments to safety net hospitals that serve more patients at high social risk,
• rewarding hospitals that reduce health disparities through alternative payment models
• using the nonprofit hospital tax exemption as a tool to expand care to marginalized populations and invest in community health

Are you a Top Hospital? Learn how to share your performance!

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Racial equity and drug approvals

Racial equity has been a growing topic of conversation regarding drug approvals. Confronting structural racism requires dialogue with all actors in the healthcare system. However, what could be a fruitful conversation has been largely co-opted by pharmaceutical companies and pharma-funded groups as a method for trying to get drugs with unclear benefits approved.

At the recent Makena hearing, one of Covis pharmaceuticals’ key arguments was that Makena should remain on the market as a health equity intervention, because the drug may benefit Black women. This claim is based on the fact that a 2003 trial of Makena was positive, and this trial was conducted in the US with a majority Black women in the trial. However, there were some serious methodological flaws that called the results into question.

Makena’s manufacturer was required to conduct another trial, called PROLONG. This trial had a larger international cohort (since Makena was already on the market in the US, it was harder to recruit American women for the trial) and participants were mostly white women. This trial did not find a significant effect on preterm birth, regardless of the participants’ race, risk level, or other characteristic. The FDA wrote they were “unable to identify a group of women for whom Makena had an effect” in the confirmatory trial.

The differences between the two trials does not mean that the drug is effective in Black women. Neither trial showed a difference between drug effectiveness by race. The PROLONG trial had three times more participants than the previous trial and did not have the methodological problems as in the previous trial. PROLONG was designed to confirm that Makena decreased preterm birth-related health issues for infants, and not only was there no difference in infant health, but there was no different in the surrogate outcome of preterm birth at 37 weeks.

Given these findings, keeping Makena on the market would be a deeply inequitable decision. Because Black women are more likely to be at high risk for preterm birth, they would be more likely to be prescribed this unproven drug, and thereby exposed to unnecessary risk of drug side effects including headaches, depression, and cancer.

Let’s not forget, drug companies did not rush to get Makena approved because they cared so much about racism. Makena is a branded form of a very old $10 drug that was repackaged by a drug company and sold for $1500. Medicaid has spent $700 million on Makena in the past three years alone.

Pharma-funded claims

The FDA was not swayed by Covis Pharmaceuticals’ claim that the drug should stay on the market for purposes of racial equity. But it is concerning to see the crucial topic of racial equity being used to advocate for ineffective drugs. Covis did a great job spreading their message (read: money) around to specialty and advocacy groups to get their support. In many cases, pharma-funded groups brought up the issue of racial disparities in Makena’s defense.

For example, the senior advisor for HealthyWomen (Covis is on their corporate advisory council) wrote in a comment to the FDA, “Now is not the time for the FDA to exacerbate an ever increasing maternal health disparity in maternal and infant health outcomes between Black, Indigenous, and women of color and their white counterparts.”

Other specialty groups including the Society for Maternal-Fetal Medicine and the American College of Gynecology received funding from AMAG Pharmaceuticals, the previous owner of Makena. These and many other organizations belong to the Coalition to Advance Maternal Therapeutics, which is funded by Covis and other pharmaceutical companies. Covis also funded the creation of a group by the National Consumers League called the Preterm Birth Prevention Alliance to share patient stories about preterm birth at the FDA hearing.

Next in a pattern

Covis Pharmaceuticals isn’t the first to argue that an unproven drug should kept on the market for the sake of racial equity. Drug company Biogen used a similar argument to urge Medicare to cover their Alzheimer’s drug Aduhelm. Biogen and pharma-backed patient organizations called CMS’ decision to restrict access to the drug “discrimination” since people of color are at greater risk for Alzheimer’s.

Biogen, the makers of Aduhelm, claimed the CMS decision would “exacerbate health inequity in dementia care.” And the Alzheimer’s Association, a patient organization that receives funding from Biogen, called the decision “shocking discrimination against everyone with Alzheimer’s disease, especially those who are already disproportionately impacted by this fatal disease, including women, Blacks and Hispanics.” This argument ignores the fact that we don’t know if Aduhelm actually works to reduce Alzheimer’s symptoms or progression, and that Biogen did not recruit enough people of color in their trials to match the levels of Alzheimer’s seen these groups.

And again very recently, the head of a pharma-funded advocacy group penned an op-ed in StatNews arguing for more access to PET scans for the sake of health equity — so that Black people could more easily access Alzheimer’s drugs that haven’t been proven to work.

What we need to talk about

Achieving racial health equity is incredibly difficult. It will require all actors in our health system — doctors, patients, hospitals, insurers, government agencies, pharmaceutical companies, etc. — to tackle structural racism at its core and to put power into the hands of communities most impacted by racism. The idea that unproven drugs like Makena and Aduhelm can solve racial disparities is a tempting shortcut, but a very misguided one.

Imagine that we did uncover a drug that cured Alzheimer’s disease, preterm birth, or another of the many health conditions more likely to impact people of color. Black, Hispanic, and Indigenous Americans would still be less likely to access this hypothetical miracle pill because of factors created by structural racism. People of color are less likely to have health care coverage than white Americans, less likely to be able to afford out-of-pocket costs for drugs, and less likely to be prescribed drugs that work.

The idea that unproven drugs like Makena and Aduhelm can solve racial disparities is a tempting shortcut, but a very misguided one.

Many people of color already have trouble accessing medications that already exist. Black individuals with atrial fibrillation are significantly less likely to receive direct-acting blood thinners (the safest, most effective type of blood thinner) than white patients. People of color are also less likely to receive buprenorphine for opioid addiction and more likely to report underuse of diabetes medications because of cost. And during Covid-19, Black and Hispanic/Latinx individuals were less likely to have access to antibody therapy or other novel treatments.

Racial health equity will not be attained through spending hundreds of millions on unproven drugs. We have to address the structural racism that leads to these disparities. That means implementing universal coverage, addressing provider unconscious bias, tackling residential segregation and hospital segregation, improving the social conditions in communities of color, and a myriad of other policies.

For their part, drug companies can ensure they represent all Americans in clinical trials, invest more in research for underfunded conditions that predominantly impact people of color like sickle cell anemia, and stop raising their prices unnecessarily (discounts through charities don’t count).

Racial equity is a real goal that we all need to work together to strive for — not a talking point to market unproven drugs.

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When trust disappears, mental health plummets

The Flint water crisis is well-known and infamous. After the city chose to switch water sources in 2014, residents complained of dirty, smelly water coming through their taps and making them sick. City officials denied anything was wrong until Dr. Mona Hanna-Attisha — also the winner of the 2021 Bernard Lown Award for Social Responsibility in Healthcare — collected data and found that the blood lead levels of her pediatric patients had doubled. Her team blew the whistle at a public press conference and forced the city to start working on solutions. The recovery has been bumpy, and as of March 2022 the Environmental Protection Agency (EPA) was still recommending Flint residents only consume filtered water.

The water crisis began quickly and has lasted a long time, so it’s no surprise that the residents would feel the mental toll it takes to navigate their situation day-in and day-out. In this most recent longitudinal study, researchers successfully recruited 1,951 Flint residents to complete their survey five years after the onset of the water crisis. They found that 1 in 5 residents met criteria for depression, 1 in 4 for presumptive PTSD, and 1 in 10 for comorbid depression and PTSD. Sociodemographic factors were significantly associated with meeting these criteria, suggesting that the water crisis exacerbated an already-brewing mental health crisis. Unsurprisingly, researchers also connected a lack of confidence in public health information and officials to higher risk for depression, PTSD, and comorbidity.

Inequities played their role in the Flint water crisis. Like climate disasters, when infrastructure collapses in majority Black, working-class areas, recovery is slow. In 2017, a government-appointed civil rights commission affirmed what many Flint residents already knew – that systemic racism combined with implicit bias had contributed to the city’s crisis.

Flint – not even the first, definitely not the last

As this study was being conducted and released, we’ve had plenty more water crises. Right now, Jackson, Mississippi is gaining a ton of press for their contaminated water crisis caused by historic flooding back in August. In California, both schoolchildren and incarcerated individuals may be exposed to contaminated water. In June, the EPA issued guidance to all of the 2.7 million residents of Chicago to avoid their drinking water. This past Wednesday, The Guardian reported 1 in 20 tap water tests in Chicago found lead. Before Flint even happened, there was a 2004 water crisis in Washington, DC. 

Some of these were due to cost-savings schemes or hard-to-update infrastructure, others were due to natural disasters. What’s clear is that we do not have as secure a hold on clean, drinkable water as we need to have. The EPA has been pushing for water infrastructure improvements as well as for voluntary, regular lead testing, but these efforts take years of concentrated efforts. While no area is immune, these crises tend to pop up and persist in communities with less resources and display our significant equity issues in terms of infrastructure and support. Unless we address these inequities, unless we pour our resources into preserving the life-supporting systems like our water pipes and infrastructure, we’re going to continue to see these crises pop up in the coming years. And as this most recent study shows, the impact of failing to do so can last for years.

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The Social Determinants strike again

As with most health equity problems, the root causes are deeply entrenched in how we’ve chosen to run our society. The social determinants of health, as the name suggests, determine the likelihood of health outcomes. Right now, our system is harming Indigenous American and Alaska Native (IAAN) people through social factors like racism, environmental pollution, shaky access to clean water, and limited access to nutritious foods. In fact, Indigenous American and Alaska Natives are 400% more likely to face food insecurity as compared to peers, and an estimated 20% lived in poverty before the pandemic made conditions even worse. 

Prior to COVID-19, there was already a 2 year life expectancy disparity between Indigenous American and Alaska Native populations as compared to non-hispanic white Americans. Some of the leading causes of death amongst this population include heart disease and diabetes and risk factors with high rates include obesity, mental health, and substance overuse. obesity, mental health, and substance overuse. These conditions require access and regular contact with the healthcare system – however, these populations also tend to have less access to healthcare due to the rural nature of most reservations. The Indian Health Service (IHS), meant to fix this exact problem, is chronically underfunded, leaving those who don’t live in urban areas without many options. And despite high rates of health disparities, IHS spending for patient health services per person is just a third of the national average. Many of the states with reservations have chosen not to expand Medicaid, which compounds the financial barrier to healthcare access.

Health Equity Impacts are Exponential

Going into the COVID-19 pandemic, these disparities already existed and were impacting the health and wellbeing of the Indigenous American and Alaska Native populations. When the pandemic hit, it became clear that personal health was a major factor in health outcomes. It also upended everyone’s lives and threatened the status of many people’s income, stress, housing, and food security. Given the disadvantages faced by the Indigenous American and Alaska Native populations, it’s clear to see how these issues influenced death rates and have snowballed into a drastically different life expectancy for these populations.

Few escaped COVID-19 unscathed. With the data that we have now, it’s easy to trace the link between diminished quality of social determinants and decreased life expectancy – the more healthcare hardships faced in general life, the more impactful COVID-19 is on health outcomes and death rates. 

“There is nothing weird or unusual about our population. This is simply what happens biologically to populations that are chronically and profoundly stressed and deprived of resources.”

Dr. Ann Bullock, former director at IHS and member of the Minnesota Chippewa Tribe to The New York Times

As depressing as these health inequities are, there is a clear leverage point for change. We know that the lack of investment in  Indigenous American and Alaska Native communities creates harm every day. To start, Congress could adequately fund the IHS. Congress also just passed up the opportunity to curb insulin prices for everyone, which could have had a huge impact on the 14.5% of Indigenous American and Alaska Native adults who live with diabetes. Ensuring clean water would be a huge step, especially given recent challenges around the lack of piped water in Navajo communities specifically. Easy access to affordable, nutritious foods could help with high rates of diabetes. Increasing mental health care through an increased workforce and utilization of telehealth could help bring down rates of substance overuse and, eventually, cirrhosis through counseling while simultaneously fortifying mental health and resiliency. 

We have the means to help the Indigenous American and Alaska Native population not just survive but thrive – it’s well past time that we improve on the social determinants of health that ultimately determine our lifespan.

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