Race and wellness – Part III

Mending the inequities

“The COVID-19 pandemic has certainly laid bare the health inequities that we have in our society. There has never been a time that the social determinants of health have been exposed so clearly, so rawly. People in vulnerable communities are dying from a disease because of their race and because they’re poor. That should not be acceptable in the richest country on earth.”¹

–  Robert Harrington, MD, Chief of Medicine, Stanford Medicine

In this, Part III, of our series on race and wellness, we begin the discussion of possible solutions aimed at mitigating the unsettling inequities in our healthcare system, especially along racial and socioeconomic lines. The analysis began with Race and wellness – Part I: Examining health disparities; and continued with Race and wellness – Part II: Going beyond the data. 

Once again, we are indebted to the expert consultation of N. Kenji Taylor, MD, MSc, AAHIVS — an instructor of medicine at Stanford Medicine, a physician with Stanford Health Care and Roots Community Health Center (Oakland, CA) and a member of the Stanford-Intermountain Delivery Science Fellowship.

Fixing racial disparities: The ambitious plan

Dr. Taylor cites the following “solutions” as necessary for mitigating the health disparities that are the hallmark of COVID-19 (and so many other diseases and conditions). It is a long, broad and ambitious list:²

• Expand housing
• Provide food
• Expand healthcare coverage
• Support education
• Improve computer and internet access
• Protect workers
• Partner with community members
• Expand accessible testing
• Provide safe and viable transportation options
• Pass policy initiatives to address disparities at the local and federal levels

The importance of community health partnerships

Taylor believes strongly that community health partnerships are a vital strategy aimed at narrowing present gaps in health equity. While a solution category that may sound modest compared to such grandiose ones as “expanding housing” or “supporting education,” Taylor nonetheless is convinced that these community partnerships are an essential component of the solution set.

Roots Community Health Centers, in East San Jose and East Oakland, is an example of such a partnership; and Stanford, with Dr. Taylor, began partnering with Roots in 2019. These community health centers service a Medi-Cal population focused on people of African descent. Taylor both sees patients and works on research evaluation projects aligned with the goal of reducing health disparities.

Roots embraces the “Whole Person Care Model,” and key to that model are the training and hiring of a large staff of “health navigators” from the community.

“We focus not only on medical and integrative behavioral health, but also integrated food, employment, benefits and economic empowerment.”

The Roots-Stanford partnership focuses on three main areas:

• Testing
• Information sharing
• Research

On the testing front, Roots has grown from performing 150 tests, with a 7-10-day turnaround time, across four sites, in March; to performing over 2,000 tests, with a one-day turnaround, across multiple partners, in June. Information sharing now spans weekly Grand Rounds, occupational health guidelines, conference calls with lab and operational personnel, a daily dashboard and clinical questions database and telehealth scaling workflows. On the research front, Dr. Taylor is particularly passionate. He urges Stanford researchers to consider including more groups for clinical trials where there is a lack of representation. “We’re not reaching out enough to communities.” He then elaborates that departments and schools need to work on this together with both process and marketing to discuss why it is important to have greater diversity in the research population:

“We need to support more and deeper relationships with community partners that go beyond doing research on  the community and move towards doing research with  the community. Having faculty/staff/resources/committees that span Stanford and community organizations is really key to building trust. It is also a powerful way to include communities in the research process from the beginning…. With longitudinal relationships, researchers start to have a better understanding of community needs and community partners start to have a better understanding of how they can advocate with academic partners like Stanford for their communities.”

At Roots, Taylor is a part of the research evaluation committee that actively evaluates research opportunities across the domains of: mission alignment, service delivery and resource demand, and trust of the partner. Involvement of community partners early in the process really improves the chances of research-community alignment. Goals on the research front include the development of wearables for symptom tracking, rapid needs assessment tools and serology testing for essential workers.

Dr. Taylor also founded, in 2010, the Cut Hypertension Program, which partners with barbershops to provide health prevention, community building, outreach, and treatment for African American men. Hypertension, a condition putting individuals at risk for cardiovascular disease, is also a condition associated with significantly higher risk of faring poorly if becoming ill with COVID-19. (See the BeWell report, Heart health: Now more than ever.) In the Cut Hypertension Program, barbers are trained to provide blood pressure readings and guidance for opening up the conversation to broader health issues impacting the community.

As the pandemic has shut down many barbershop partners, The Cut Hypertension Program has convened a core barber lead group in the Bay area to develop a national COVID-related needs inventory, provide technical assistance for safe re-opening of shops, completed a mask drive gathering 2000 masks for barbers, and will be convening a national group of 10 Black barbershop programs to kick-off a national learning community. Most recently, the program has also partnered with the Alameda County Department of Public Health to build a team of barbers and cosmetologists in East Oakland to be re-trained as contact tracers and contact investigators. Taylor is also exploring an outdoor barbering concept in Oakland at a Roots clinic linked to COVID testing and health outreach.

Universal health coverage: An eventual necessity?

When you ask leading health care industry experts (administrators, physicians, scientists and public health experts alike) today about whether it would be beneficial to the overall quality of health care in the U.S. if we ever legislated a single-payer system of universal health coverage, the answer is almost always a resounding, “Yes, of course.”

Uri Ladenbaum, MD, MS, Stanford professor of medicine, in his recently published opinion paper in Annals of Internal Medicine, eloquently frames the issue this way:

“Reasonable people may disagree on the prescription for remedy. But it is now inescapable that our moral duty extends to fighting for universal access to high-quality health care, including preventive care, for everyone. In modern life, in a rich country, it is a human right.”³

In a recent presentation, Fernando Mendoza, MD, MPH, professor of pediatrics and the associate dean of minority advising and programs at Stanford, voiced a remarkable level of optimism that our country may be on the brink of seriously evaluating major changes in how we pay for health care. Under a single-payer system, he notes that “every patient will be the same.” His hope:

“[Since] a large portion of our nation now has no work, and many are losing their health insurance, we may be at a time — like in the Great Depression — that a major social effort will be made to give everybody health care. If this is the case, then think about everybody having Medi-Cal … that no patient is going to be different than another patient based on insurance.”⁴

It’s about racism, not just race

While Dr. Taylor concurs that a single-payer system “will have a [positive] impact on diversity,”  he cautions that “we can’t really forget to talk about all the other things that impact [inequities] … how racism underlies all these issues as well as all the social determinants of health … and how community partnerships are such an important part of really making a dent in this issue.”

Some of the larger health care institutions, including Cleveland Clinic and UCSF, seem to be heading in just that community connection/support direction, and on a much broader scale than ever before. Both organizations have declared that they will be transforming into “anchor institutions” to “leverage their power and funding to promote health equity and equality by redirecting their hiring and investing practices to local residents and local businesses” while also “improving and funding local education and public housing.”⁵

Dreaming big as well, Dr. Brian Williams, an associate professor of trauma and acute care surgery at the University of Chicago, speaking on a recent American Journal of Bioethics panel, states that “radical inclusion” is what must occur for health disparities to become a thing of the past:

“Imagine if we took the energy and money that was put into isolating black people, brown people from the rest of society and made efforts to radically include them in mainstream society, how that would reduce all the issues regarding equity in healthcare, economic opportunity, education….probably, that would lead to a dramatic decrease in crime, less need for policing, less need for police brutality….”⁶

And so the issues of racial health disparity and racial police brutality are inextricably linked — not only coincidentally in time, and in the year 2020 especially, but also in import, meaning and direction. The cures for both most certainly have common, overlapping components: communication, collaboration, education, inclusion, prevention, protection and accountability.

Hopefully, we can start and finish something  of relevance in these areas. It’s so about time.

By Lane McKenna
August 2020

Sources:

1. Harrington, R. Stanford Department of Medicine Grand Rounds: June 3, 2020.

2. Haynes N., Cooper, L., Albert M. et. al. At the Heart of the Matter: Unmasking and Addressing COVID-19’s Toll on Diverse Populations. Circulation. 2020 Jul 14;142(2):105-107. Originally published May 2020.

3. Ladabaum, U. Life after May 25. Annals of Internal Medicine. August 4, 2020.

4. Mendoza, F. and Taylor, K. Stanford Department of Medicine Grand Rounds: June 10, 2020

5. Panchal, A. Health Inequity: Guiding UCSF to a Broader Civic Role. San Francisco Chronicle. July 19, 2020.

6. Williams, B. Black Bioethics: Racism, Police Brutality, and What it Means for Black Health. American Journal of Bioethics. July 18, 2020.