Towards Equity-Centered Care

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A “Health in All Policies” framework has been touted in the past few years as a strategy to illuminate the intersections between public health and other areas of civic life. It’s one way to incorporate health metrics into existing and proposed public policy – from education to transportation. But the question is, will it work?

It seems fairly obvious that health-centric framing may obstruct interdisciplinary collaboration. But at a more fundamental level, will replacing multivariate, silo’d interests with the singularity of health effectively capture the complexity necessary to create shared agendas across public sectors?

The short answer is no. Here’s why and how we got here.

The former structure of medical education and training was rooted in the idea that the greatest knowledge in medicine was best revealed through individual patient inquiry and the greatest challenges in the field were best understood and addressed through individual clinician excellence. So clinicians were evaluated based on their individual aptitude, patients were assessed based on their isolated symptoms, and each sector of the health and human service network operated in silos, training and treating pieces of the problem, without ever quite appreciating the inter-connected whole.

This paradigm of education and practice placed clinicians at the center of care and patients and allied partners at the periphery. Allied learners were taught separately and systems communicated poorly, both of which resulted in fragmentation – in how problems were evaluated and in how care was delivered.

A more recent iteration of this care ecosystem, like the “Health in All Policies” approach, now places patients and health at the center of delivery models and public policy strategies to treat disease and advance wellness. These patient-driven, health-specific metrics ensure that systems are oriented to serve and public policies are structured to mitigate health impacts.

However increased focus on individual patient outcomes may obscure population-level drivers of health disparities and unilateral dependence on health as the primary outcome, may ostracize allied disciplines, institutions, and learners whose work or study contributes to advanced understanding of human behavior and the complex relationships between structural environments and the pathophysiology of disease.

The bottom line is: the intricate problems that threaten child and community health will not be solved by the individual capacity of excellent clinicians or public servants, but rather by the ability of leaders to organize interdisciplinary teams that learn, work, communicate ideas, translate interventions, and are evaluated across shared infrastructures, in the service of shared outcomes.

If identifying health as the primary outcome of interest or individual patients as the primary drivers of systemic priorities, alienate important partners and dilute the input of minority populations, it is time for a new centering principle. In my mind, that principle should be equity.

Placing equity at the center of the care ecosystem ensures each sector of the health and human service network and each provider and recipient of care has a role and contributes to the shared societal realization of public safety, economic security, and wellness.

Shared values, like equity, are important foundations for building integrated public systems. And integrated public systems are important to create parity in resource dissemination and improve productivity through partnership with allied disciplines and institutions. Although the process of integration may generate new financial costs, it will hopefully save money on the back end by aligning incentives and improving efficiency.

In the end, equity will be the framework for the future of care and policy that aims to improve health. So as we move towards the future, let equity be our guide.

* In appreciation for their wisdom: I want to acknowledge Dr Rajiv Bhatia who’s novel work on The Civic Engine, and Dr. Damon Francis whose generously shared expertise, informed the ideas presented in this piece.*

Black on Black Crime: Let’s Talk About It

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After publishing a few pieces on police violence, public health and safety, I received a number of comments asserting the “real” problem is black on black crime. I get this a lot.

So let’s talk about it.

According to the numbers, the most recent of which come from the FBI’s 2014 crime report, the critics are right. Black victims of homicide were overwhelmingly killed by black offenders. This occurred in almost 90% or 9 out of 10 homicides and includes both male and female victims and offenders.

BUT…

This is also true of white on white crime.

In fact, most victims of homicide are killed by someone of the same race or ethnicity. For white people, more than 8 out of 10 homicide victims die at the hands of another white person. And though Latinos have the highest rates of inter-ethnic homicide, 7 out of 10 victims still succumb to a fellow Latino.

So while it is true that black on black crime accounts for most black homicides in America, racial congruence between homicide victim and offender is hardly unique to African-Americans.

What is unique is the rate at which African-Americans are killed by police.

Let’s review the evidence.

Most data on police-related deaths come from the FBI and Bureau of Justice Statistics. The FBI counts deaths they term “justifiable homicides” or incidents in which the victim was a felon shot in the line of duty. The Bureau of Justice Statistics data is more robust, in that it includes deaths resulting from any use of force while a civilian is in law enforcement custody.

However, these agencies have been¬†criticized for generating unreliable and out-dated data. For example, the exact number of “justifiable homicides” are difficult to pinpoint in any given year, because the tally relies on precinct reporting that is largely voluntary and often incomplete. And the Bureau of Justice Statistics’ most recent metrics are from 2009, and have since been replaced by the Death in Custody Reporting Program, whose latest data is from 2012.

This lack of accurate data clouds the public’s ability to understand the racial context surrounding recently publicized police-related injuries and deaths, and may be leading some to short-sighted conclusions.

The good news is, people are working on it.

Powered largely by news reports, social media announcements, and civilian tips, crowd-sourced databases and other open access portals are keeping public records on incidents of police violence and most importantly, providing real-time, interactive access to the critical numbers necessary to appreciate the size and scope of the problem.

But one database in particular, Mapping Police Violence, is leading the way in illustrating how this issue uniquely affects African-Americans.

Here are 3 moving charts from their work which chronicles police violence from

January 2013 to Dec 29, 2015.

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These findings are alarming. But what is more disconcerting are assertions that the deaths of some Americans are not “real” problems because those same people face additional threats to health and safety in their communities.

It is certainly easier to indict “cultural” pathologies instead of confronting systems that serve us – systems we pay for and participate in – to demand for our neighbors what we demand for ourselves. But the legacy of racism that results in poor, communities of color suffering heightened risk of violence, displacement, and resource scarcity, continues to structure vital access to justice and safety.

Thus, perhaps the “real” problem is our collective inability to feel empathy on behalf of communities facing complex and compounding traumas, traumas we contribute to through our general apathy for a people and their color.

The Arc of Injustice: How Racism Kills

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The tragic deaths of Oscar Grant, Michael Brown, Eric Garner, Tamir Rice, Walter Scott, and untold others, deeply grieve our national conscience. But more black men die in America from heart disease than from police brutality, and we never mention those parallel realities in the same breath, let alone collectively mourn those dead.

Why is that?

Because it’s not just that African-Americans have higher rates of heart disease and its related risk factors. It’s that being black IS a risk factor for dying from heart disease in America. Yet few connect the dots between black death by police and black death by disease, although both disproportionately take of black lives.

Just look at the data.

Evidence shows African-Americans have a shorter life expectancy and higher rates of illness and disease than any other racial or ethnic group in the country. Even black babies are more than twice as likely to die before their 1st birthday than other infants in the US. Considering America’s overall infant mortality rate ranks behind its first world peers, that finding is far from benign. In fact, it makes African-American babies less likely to survive the first 12 months of life, than babies born in Botswana, Cuba, or Kuwait; to name a few of the 94 countries who have better infant mortality rates than black newborns in the United States.

And these gaps are far from new. Back in 2004 Congress asked the Institute of Medicine to investigate these racial disparities. After reviewing more than 100 studies,

“The committee was struck by the consistency of the research findings [that] indicated minorities are less likely than whites to receive needed services, including clinically necessary procedures.”

For almost every disease studied, black patients received less effective care than white patients, including routine treatments for common health problems; from cancer and diabetes to, you guessed it, heart disease.

Now, I know what you’re thinking. Just because African-Americans are disproportionately sicker and die younger, doesn’t mean common medical practice added to the disparity, right?

Wrong. Titled Unequal Treatment, the authors concluded,

“(Al)though myriad sources contribute to these disparities, evidence suggests bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care. “

There is something about being black in America, that places African-Americans at increased risk of death; and that something is a quantifiable systemic bias.

So while it is important to scrutinize policing practices that disproportionately harass and kill black males, we must also critically appraise equity in health and healthcare.

How else will we explore the extent of the injustice weathered by Eric Garner who ultimately died of a heart attack? Police training may prevent his unprovoked asphyxiation, but it would do little to address an already shortened lifespan. And yes, the banned chokehold and subsequent failure to indict seemed unjust, on the surface. But is it right to invoke Garner’s haunting last words as a rally cry, if we ignore the inequity that may have pulsed beneath the surface?

And how can we learn from Darren Wilson’s description of Michael Brown as a “demon…bulking up to run through the shots, like it [made] him mad that I [shot] him”? Could the former officer’s misinterpretation of anguish, on the face of a black youth who sustained multiple gunshots, be related to medicine’s well-documented racial disparities in pain management? Because in healthcare, data indicates black children and adults are less likely to have their pain accurately perceived and appropriately treated; and this mistreatment limits medicine’s ability to protect and serve black patients well.

In reality, the threat of police violence that endangers black lives is intimately related to the threat of death and disease that disproportionately burdens communities of color. These are not isolated issues. Together, they tell of a nation that remains profoundly influenced by race, from the mandates of justice to the delivery of healthcare. In time, that influence ceases to publicly alarm. So while some black deaths are made a media spectacle, the vast majority go unacknowledged and unaddressed; the collective impact of which subtly normalizes inequity and codifies injustice.

In the end, there will be no justice without accountability. To save black lives, we have to change how we think about black life – not just how or if, it matters, but where and when, it is most at risk. Now the arc of injustice includes the well-intentioned and malicious alike, each of whom may harbor attitudes and preferences that ripple across systems and threaten the lives of people of color. These threats expose the reality that racism kills and the death toll is much greater than you think.

Is Civic Engagement the New Frontier of Physician Advocacy?

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We Can Do Better - Improving the Health of the American PeopleThe figure is simple. Health care plays, at best, a minor, and at worst, a relatively inconsequential role in reducing early death in America.

That means, where people live and how they function in their local environment, potentially matters more to their long-term survival than what doctor they go to, or what medicines they are prescribed.

That is a powerful statement about a complex phenomenon – what happens in our communities impacts health in profound and lasting ways. So if health is predominantly determined by community-level factors,* perhaps we should re-design the traditional medical model to place community at the center of health care.

This idea isn’t new, and is probably why Dr. Steven Schroeder aptly titled the article from which this graph was taken, We Can Do Better. One look at the data and it is obvious more can and should be done to address the social, economic, and political drivers of health in this country. But the question of who and how somehow remains.

For many physicians, taking on structural inequality may seem overwhelming or outside their job description. Common retorts I hear are, “This is a social workers job.” Or “This sounds good in theory, but how would it work in practice?” To the first point, the evolution I am alluding to is a systems-wide change in the practice of medicine, such that the way we conceptualize medical care draws upon the skills of an interdisciplinary team of practitioners charged with addressing social determinants of health. So while this vision certainly includes social workers (and public health departments, local government, social service agencies, etc) it also necessarily includes physicians.

To the second point, there is a long history of community-oriented primary care (COPC) theory and practice. It dates back to the 1940s, and the work of giants like Sydney Kark, who created a model of government-funded, community-based, preventative care delivery in South Africa; and Jack Geiger who directed 2 exemplary, community health centers in the Mississippi Delta and Boston, MA in the 1960s. Dr. Geiger’s integrated clinics were the first of their kind and used government funding to pay for community-level health issues, like hunger and housing. Today, there are over 1200 such clinics nationwide serving an estimated 20 million Americans, or 5% of the US population, annually. These clinics are the backbone of the national safety net and the front lines of the medical response to growing inequality.

But as the issues of poverty begin to knock on all of our clinic doors, we can no longer afford to ascribe to the notion that this is the niche work of a minority of physicians.

So where do we begin?

The ballot box.

Data suggests physicians have a relatively low rate of civic participation as compared with professional peers like lawyers and the general population. As local policy informs local resources, the ballot box is the space where physicians find voice to address the pressing needs of our communities, needs that have an undeniable impact on this nation’s health.

The future of medicine requires physicians confront the impacts of concentrated poverty, a tiered education system with gaps big enough for entire communities to fall through, immigration and population displacement, and racial and gender discrimination, among other indicators of health. Still, the traditional physician role and our current training paradigms largely ignore these modern threats to health and wellness. So in the absence of a clear system-wide charge, vote in a way that makes a difference.

If community health centers are the backbone of the social safety net, voting is the backbone of physician advocacy.

Civic participation is the new frontier for physicians to combat the effects of poverty and inequality on health in enduring ways. It is how we can reach beyond the limits of our clinical role to engage the issues that matter to our patients and our communities.

Visit Vote411.org to find a polling place near you, trouble shoot election-day problems, and find a state-specific voter guides.

Definitions used in this piece:

* Community-level factors are things like where you live, how safe your neighborhood is, if you have a park within walking distance of your house, or if the property values in your neighborhood are high enough that your local public school is well-funded and thus if you are of school-age, you are more likely to go to college as a result of living in that neighborhood. These community-level factors are intimately related to the choices people make or their “behavioral patterns” (as referred to in the pie chart above). For example, if your neighborhood is relatively safe and there is a park within walking distance of your house, you may be more likely raise your child in a lifestyle that promotes and values physical activity, a known method to prevent obesity. Conversely, if you live in a neighborhood that does not have a grocery store that sells affordable fresh produce, you may be more likely to eat processed food, and more likely to battle obesity and related health conditions.

For more on how community level factors or structural inequality affects health, check out my piece on structural inequality here. If you are an educator thinking about teaching these topics, check out my piece on teaching structural inequality here. This piece also includes the syllabus and reference guide I use when teaching on this topic.