How Can the Healthcare System Achieve Health Equity?

In your talk you said, “pick a race or ethnicity of any sort, and you’ll find a disparity.” Can you speak more about what you see in your specialty?

It doesn't take much effort to find disparities when it comes to cardiovascular disease. From a population health standpoint, the large majority of the minority patient populations with hypertension are not aware that they actually have this major contributor to cardiovascular disease. And if they do know they have it, it’s not managed effectively. If you go down the list of things that we can be doing to actually address cardiovascular disease disparities, you see that we’re not actually addressing the root causes. And from my clinical lens, people are not being prescribed the right medications. 

We have a healthcare system that is not designed to address the root causes of disease beyond prescribing medications. That is unfortunate, as a large majority of vulnerable patient populations really want to learn how to be better at taking care of their own health. But we don’t provide that for them in our healthcare settings. 

The systems that we provide to address healthcare, unfortunately, have inequities baked right in. Here’s a quick example. There was a study about a new class of medication to prevent heart attacks and heart disease. The study found that this drug was prescribed to minorities at much lower rates, which wasn’t surprising since we see this all the time. But they looked a little deeper and found the disparity centered on whether the patient had insurance or not. We have this system that creates winners and losers based on their job. So from my perspective, if we’re really going to focus on improving disparities, we either need to circumvent the insurance system or actually improve insurance.

Tell us about your research.

My research spans the gamut. I look at policy, and I use modeling to simulate interventions related to decreasing disparities, whether place-based disparities or in individual populations or for individuals themselves. From there I extrapolate what we should do, pragmatically. One of the examples I talked about recently related to existing public funding. 

Here at the university, 1% of our paychecks go to the government toward prevention efforts. There are a lot of community-based organizations that receive this public funding to do things around blood pressure management for community members. As clinicians in the healthcare space, we don’t think to use these community-based organizations as a source to do interventions. There’s a pragmatic linkage here – these are pre-funded interventions that we in the clinical space could be better about using to improve healthcare and address disparities. And we know we have tons of people in these community-based organizations that are addressing heart disease among women of color, but we're not integrating them into how we deliver care.

How have you incorporated community-based organizations into your research?

We’ve been funded by the Colorado Department of Health & Environment to connect community organizations with primary care practices to integrate care delivery for high blood pressure. Just this week we started a project with a community-based organization called FIT & NU. They are two African American sisters who started by doing Zumba classes for church members at a predominantly Black church. So they started by just teaching classes, then created this whole company around addressing health and nutrition with women of color. They’ve grown to include blood pressure management programs that are evidence-based and funded by the CDC (Centers for Disease Control and Prevention) and the state. 

So my question became, why aren’t we referring our patients to this? One thing we know is that we can do a substantially better job in our clinical settings addressing blood pressure. And here we have these community members doing a wonderful job of helping their community manage blood pressure. It’s another example of the community knowing what it needs, so the question remains: How can we as the healthcare system be part of these interventions? How can we fit ourselves within existing systems and support our patients?

What’s bringing you hope right now for improving these areas of disparity?

The responses from the community are giving me hope. Also, what I keep hearing from the state and funders is that they want to address these disparities, but they just don’t know how. I think that there's a huge gap in the research and that it's our job within the clinical spaces to provide those solutions. The market is thirsty for it, and we just haven't come around to it. The most surprising part is that people have been doing this type of work, addressing these disparities, for decades now, but no one really considered the impact of this work. It’s easy for researchers to call out the disparities. My research is about finding ways we can do this better and focusing on how we’re going to fix it.

What do you encourage your fellow researchers to think about as they do systems-level work?

You know, the outcomes that we see within the system – they are the exact outcomes the system is built to achieve. And we can stop there and recognize, OK, there's some dysfunction here. And we can all point this out, but what we need to be doing is focusing on the small things we can do in our clinics and beyond to make a difference.

 For example, there are more Black men who smoke cigarettes than need to be smoking cigarettes, so how can I incorporate smoking cessation in my clinic? Who is already doing this work in the community? As researchers, we have a lot of people who sit on guidelines and committees, and these aren’t spaces that I’m necessarily privy to. I obviously come here with some level of privilege. But I recognize that I need to see how I can expand my lens for the work that we are doing here to address health inequities.

What was your pathway to this work?

Well, I'm a first-generation college student. I was extremely lucky to have parents that kept me out of trouble as much as they could. And counselors at high school who were determined to not let my talent go to waste. I didn’t have any resources or understanding of how to even apply for college. Many of my colleagues didn’t have this experience. And if you don’t have this lens, I understand that it’s easy to blame the individual for their poor health outcomes. I want people to appreciate the luck they had of being born to parents that live in the neighborhoods in which the police weren't highly hostile toward you or murder rates weren’t sky high or you weren’t scared to go outside. It's OK to say I don't understand that lens, but I'm willing to learn.

Even with all the research about health disparities, do you find it’s hard for clinicians to understand?

I continue to run across clinicians that look at disparities as the seed, with the flower itself as the problem. They aren’t necessarily asking, ‘Is there something within the soil itself that could be impeding the growth of this flower?’ Historically, there's much data and information that points to how we, as a system, have created problems. 

We have historically created wealth gaps in his nation, from post-slavery up until now. We're still dealing with redlining, in some capacity. If we can just acknowledge this and stop blaming the victims, then we can get to work. We blame the victim for their poor health outcome when we’ve set up a system that only works for some. People are working 80 hours a week to pay rent, working fast food jobs with no time off, and we in the healthcare system wonder why they couldn’t make their 1 p.m. appointment.

What do you think needs to happen in the future within the current healthcare system to ensure disparities are better addressed?

I think we need to be asking ourselves across the board: How do we get future physicians, medical students, nurses, etc., to think in terms of systems and to understand disparities that exist? And how can we empower them and empower our systems to always want to evolve and change things and make that normal? We can do it. We can address it. And it can be really small, practical themes. If anything, people who are working in this system need to remember to recognize that we have a system that's problematic and always leads to disparities. If we can remember this and move from this place, we might move in a better direction.

Guest contributor: Carie Behounek covers healthcare and science.