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.*

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#JusticeForFlint

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In April 2014, Flint transferred its water supply from Lake Huron to the Flint River. It was meant to be a temporizing, cost-saving measure. But what followed was one of the most devastating recent failures of public infrastructure and a heartbreaking example of how social inequity ultimately leads to public health crises.

To quantify just how bad the problem is, here’s a schematic from USA Today.

9To add insult to obvious injury, the areas of Flint most affected, were disproportionately poor, communities of color.

Last weekend, I was fortunate to join other activists and Flint community members in an online panel discussion hosted by Black Public Media about the impact of the crisis and what people are doing to address it. This weekend, as the nation prepares to broadcast the latest democratic presidential debate from Flint, Michigan, I wanted to revisit what has and is happening there, who it affects, and what we can do about it.

1. Lead is toxic.

There are no safe levels in the blood and it can affect every organ system. Adults exposed to lead can have high blood pressure, joint or muscle pain, headaches, memory loss or mood changes. In utero exposure can result in miscarriage, premature birth, and low birth weight. Children who are exposed are at risk for learning problems, developmental delay, weight loss, and hearing loss. And the most disturbing data shows maternal exposure may even be transmitted to grandchildren, making the adverse effects of lead, generational.

2. Infants and children are more vulnerable to lead exposure from water contamination.

Infants and children can absorb more water-soluble lead than adults. And infants whose primary nutrition is reconstituted formula mixed with contaminated tap water, likely absorb the most.

3. Low-income, people of color are increasingly vulnerable to lead exposure.

  • Aging public infrastructure in urban America means lead may leach into faulty pipes and disproportionately affect areas with concentrated poverty, which are more common in communities of color.
  • Neighborhoods with high rates of food insecurity may lack access to foods high in calcium, Vitamin C, and iron, that decrease lead absorption and buffer potential exposures.
  • High rates of unemployment and historical housing discrimination may contribute to low-income, communities of color disproportionately inhabiting older homes that increase household exposure to lead in chipping paint, dust, or soil.
  • Lack of financial resources to purchase alternative water sources disproportionately expose poor people to contaminated tap water.

4. To fix this, more than clean water is necessary. 

Access to clean water is essential to decrease water-based lead exposures but the magnitude of this exposure (2 years worth!), lead’s potent toxicity, and it’s long-term effects on cognition, behavior, and child development, will require wrap-around social services. That includes access to affordable, healthy food, education supports, behavioral health services, early childhood programs, and sustained investment in local infrastructure to mitigate the short and long-term impacts of these exposures.

Additionally low-income, communities of color should be prioritized to receive these services because they have been disproportionately impacted.

5. For more information about lead exposure for families who are affected or concerned:

When things like this happen, and know it is happening all over the country, it’s important to take an honest look at what it means. And I don’t just mean environmentally.

Americans are only as free as the choices at our disposal. And when poor people and brown people have no choice but to take poison because of failures of public systems, systems that dismissed concerns raised time and again, it corrodes the promises on which our democracy is built. From contaminated tap water to neighborhoods that lack fresh produce or communities disproportionately subject to violence or school systems that fail poor, brown youth – it is inequity that is poisoning America and betraying our unalienable rights to life and liberty.

Make no mistake, this is about more than water. And while we can bottle short-term solutions now, it is time to take affirmative steps to close disastrous equity gaps in America that underpin future crises.

Police and Pediatrics

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As many of you know, I took a 6-month hiatus from my blog last year to write and edit a piece on policing and pediatrics. I am excited to finally share my work entitled Police, Equity, and Child Health, that was published in Pediatrics this month! AND because this is a topic of public interest and concern, I’m also excited to announce the journal has agreed to allow free access to the piece online for the entire month of February! Check out the pdf version here and feel free to share your comments below. I can’t wait to hear what you all think!

For me, this issue is personal and writing and defending this piece for the past 6 months has been incredibly emotional. But it has also been one of the most rewarding experiences of my early career and I only hope to continue to push myself and my field to consider and engage issues that uniquely and disproportionately affect the health and well-being of children and people of color. To use a line from Black Lives Matters co-founder, Alicia Garza, at its best, this piece is a love letter, and I hope those who read it feel my deep love for my people and my people feel loved and cared for by me, and by proxy, by my profession.

I also want to publicly acknowledge and thank my mother, Avis Boyd, who reviewed every word, every line, and every intention of this piece. She is the backbone that kept this piece afloat when biting critique wore at my resolve. For this and everything, she is everything.

Last year, when Walter Scott died, I pleaded in exasperation, for my colleagues and my field to consider his death and the death of other young black folks an affront to our professional commitment to promote health. But it wasn’t enough. And although these words were powerful for me to write, they will not be enough either.

So I’ve also drafted a resolution to the American Academy of Pediatrics’ Annual Leadership Forum taking place this March, where the academy sets the agenda for child health for the coming year. The resolution is #71 The Impact of Adverse Police Exposures on Child Health and it urges the academy to both advocate for community and school policing policies that place children’s health first and to research and fully articulate the disproportionate impact children of color face from adverse police exposures.

If you are a pediatrician or a student member of the American Academy of Pediatrics, click here, to comment on and support this resolution, bringing the issue of policing and pediatrics across the country and helping the academy take an important step to better serve children and families of color.

If you live in the San Francisco Bay Area and are interested in joining a local coalition seeking to understand and address how police practices and policies can protect, promote, or harm health in our community, leave a comment and I’ll add you to our email list.

Happy Black Futures Month!

Freeing the “Doc in a Box”

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The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.

The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.

To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.

Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”

But the baffling thing is, that is not what is happening.

Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.

But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.

Thinking outside the “doc in a box”

In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.

The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.

It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.

If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.

There will likely always be a need for physical care of patients with ailments that require  treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.

With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.