Category Archives: Social Determinants of Health
By Sheree Crute
Every few weeks, Dana Todd, MD, does something rare for an American physician: She makes a house call. The visits are her way of making life easier for a bedridden stroke survivor and her caregiver daughter.
“One afternoon, I looked out into the clinic waiting room and there they were,” Todd recalls. “My patient was laying on a stretcher. Her daughter was by her side. Her family was adamantly against putting her in a nursing home because she is only in her 50s, so coming in was the only way she could get care. I just hated seeing her that way so I said, ‘Next time, I’ll come to you.’”
Todd is one of four primary care physicians who, along with a small group of nurse practitioners, provide care for residents of Greensboro, Ala., population 2,440, in rural Hale County. The little town, though, is a lot more to Todd than a place to work.
At Virginia Commonwealth University School of Medicine, Briana Mezuk, PhD, is an assistant professor in the Department of Family Medicine and Population Health, Division of Epidemiology; and Tiffany L. Green, PhD, is an assistant professor in the Department of Healthcare Policy and Research. Both are alumnae of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program.
Approximately 30 million U.S. adults currently have diabetes, and an additional 86 million have pre-diabetes. The incidence of diabetes has increased substantially over the past 30 years, including among children. Estimates place the direct and indirect costs of diabetes at a staggering $218 billion annually.1 Like many other diseases, disparities on the basis of race and income are apparent with diabetes. Non-Hispanic blacks, Hispanics, Native Americans, and socioeconomically disadvantaged groups are more likely to develop diabetes than non-Hispanic whites and socioeconomically advantaged groups.
Despite the enormous economic and social costs associated with diabetes, it remains a struggle to apply what we know about diabetes prevention to communities at the highest risk. We have robust evidence from randomized controlled trials that changing health behaviors, including adopting a healthy diet and regular exercise routine and subsequent weight loss, will significantly lower the risk of diabetes. Unfortunately, these promising findings only appear to apply to the short-term. Even worse, results from community-based translation efforts have been much more modest than expected, and show only limited promise of reducing long-term diabetes risk. In response, leaders at the National Institutes of Health have noted that many efforts at translating clinical findings into community settings are “limited in scope and applicability, underemphasizing the value of context.”2
Lisa Cooper, MD, MPH, FACP, is the James F. Fries Professor of Medicine at Johns Hopkins University School of Medicine, Director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, and an alumna of the Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program.
Have you ever had the experience of being sick and in need of help from a health professional? How about having a parent, child, other family member, or friend who had some health issue for which he or she was seeking answers? What was that like for you? How did you feel, and what were you looking for from that doctor, nurse, or therapist?
Did you ever feel afraid, and alone? Confused? That no one understood what you were going through? Or cared? Or even worse, that the health professionals may have made some assumptions about you or your family member that were wrong – even perhaps blamed you for having your condition or judged you for how you were dealing with it?
If so, you are not alone. Many people who find themselves in the role of a patient have felt these same feelings and had these same thoughts. And if you are poor, don’t have private health insurance, or if you are a person of color or belong to another minority group in our country, you are more likely than others to encounter these problems.
Susan B. Hassmiller, PhD, RN, FAAN, is senior adviser for nursing at the Robert Wood Johnson Foundation and director of the Future of Nursing: Campaign for Action. This piece is cross-posted with Off the Charts, the American Journal of Nursing Blog.
I spent the 2014 holiday season reading a book by Sarah Wildman called Paper Love. She describes how she, as a journalist, examined the fate of her Jewish predecessors, including her grandfather and his long lost love. I selected the book because my father was a Jew of Polish descent.
Wildman describes the horrific atrocities bestowed upon the Jews. Of course I knew of the Holocaust growing up, but as I get older, the connections between past and present seem to be more important. While I don’t know of any relative who was personally affected or killed, someone in my extended family very likely was. I pondered my own existence and how it may have depended on a relative escaping Europe and immigrating to the United States to escape the death camps. It is unspeakable how one man’s view of what is mainstream or normal sent so many others to their death.
I am not naive enough to believe that prejudice is a curse of the past. Stark data on health disparities continue to mount. The Centers for Disease Control and Prevention report on Health Disparities and Inequalities (2013) found that mortality rates from chronic illness, premature births, suicide, auto accidents, and drugs were all higher for certain minority populations.
But I believe passionately that nurses and other health professionals can be part of the solution to addressing these disparities. Nurses are privileged to enter into the lives of others in a very intimate way, and that means lives that are, more often than not, very different than our own.
Amani M. Nuru-Jeter, PhD, is an associate professor of community health and human development, and epidemiology at the University of California, Berkeley School of Public Health, and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program. Her research focuses on racial health disparities.
Eric Garner’s death and the failure to indict NYPD Officer Daniel Pantaleo have had a profound effect on communities throughout the United States. But it’s not just Eric Garner. This, and similar cases including Michael Brown, Tamir Rice, Trayvon Martin, and Oscar Grant, have put race relations front and center in the national debate.
I’m tired of it, this stops today...every time you see me you want to harass me, you want to stop me...please just leave me alone” –Eric Garner
These last words from Eric Garner are not that different from what we hear in our work with African American women in the San Francisco Bay area:
Janet Chang, PhD, is an alumna of the Robert Wood Johnson Foundation (RWJF) New Connections Program and an assistant research scientist at the University of Connecticut. Chang received a PhD from the University of California, Davis, and a BA from Swarthmore College. She studies sociocultural influences on social support, help seeking, and psychological functioning among diverse ethnic/racial groups.
In the past year, there has been heightened national press coverage of anti-minority sentiments, and public outcry over discriminatory incidents in the United States. The publicized nature of these events stimulated intense debate. Some, especially those who believe in racial colorblindness, have argued that outraged individuals are overly sensitive and quick to assume that prejudice and discrimination are the cause. On the one hand, this perspective provides psychological comfort by downplaying the importance of race, minimizing the impression of bias, emphasizing our common humanity, and upholding egalitarian principles. On the other hand, it is upsetting and harmful because it denies the lived reality of racial/ethnic minorities. Colorblindness renders well-documented racial/ethnic disparities invisible.
Belief in colorblind ideologies perpetuates false notions that discrimination is rare. As a result, colorblindness, along with a complex host of factors, promotes ethnic/racial disparities in wide-ranging important domains, such as health and health care, criminal justice, housing, education, and employment and advancement in the workplace. Colorblindness reinforces the myth of meritocracy, which places value on individual effort and ability but overlooks structural factors that inhibit positive outcomes for vulnerable or disadvantaged populations.
Brian D. Smedley, PhD, is executive director of the National Collaborative for Health Equity in Washington, D.C.
Relative to national averages, many people of color have poorer health from the cradle to the grave—beginning at birth, with higher rates of low birth weight and infant mortality; through childhood and adolescence, with higher rates of asthma and unhealthy weight; into adulthood, with higher rates of chronic disease and disability; and at the end of life, with higher rates of premature death and shortened lifespans.
Public health research shows that these health inequities are mostly attributable to factors beyond health care access and quality: As a result of residential segregation, people of color are more likely than whites to live in neighborhoods with a high concentration of health risks, and a relative paucity of health-enhancing resources. Highly-segregated communities of color are too often overrun with environmental health threats brought about by polluting industries, and vendors selling unhealthy products such as tobacco, alcohol, and high-fat, high-sugar, and/or high-sodium products. At the same time, many of these same communities lack access to affordable, nutritious food; safe spaces for exercise, recreation, and play; and high-quality schools that prepare children well for the high levels of education that are often protective of health.
Roland J. Thorpe, Jr., PhD, MS, is an assistant professor in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health and director of the Program for Research on Men’s Health at the Johns Hopkins Center for Health Disparities Solutions. The first RWJF Scholars Forum: Disparities, Resilience, and Building a Culture of Health was held December 5th. The conversation continues here on the RWJF Human Capital Blog.
Nearly half a century ago, Dr. Martin Luther King Jr. famously said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Yet decades later, only modest progress has been made to reduce the pervasive race- and sex-based disparities that exist in this country. African-American men who are at the intersection of race and sex have a worse health profile than other race/sex groups. This is dramatically evidenced by the trend in life expectancy.
For example, African-American life expectancy has been the lowest compared to other groups ever since these data have been collected. Today the lifespan of African-American men is about six years shorter than that of white men. Furthermore, a study from the Program for Research on Men’s Health at the Johns Hopkins Center for Health Disparities Solutions provides a financial perspective around this issue.
Lainie Ross, MD, PhD, is a 2013 recipient of the Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research and a 2014 Guggenheim Fellow. During her fellowship year, she will work on a book tentatively titled, From Peapods to Whole Genomes: Incidental Findings and Unintended Consequences in a Post-Mendelian World.
Human Capital Blog: What are some of the incidental findings and unintended consequences you will discuss in your book?
Lainie Ross: First, let me explain what I mean by “incidental findings.” Incidental findings refer to unanticipated information discovered in the course of medical care or research that may or may not have clinical significance. They are not unique to genetics. In some studies, up to one in four diagnostic imaging tests have incidental findings, although most do not have immediate clinical consequences.
One example of an incidental finding that I discuss in the book involves incidental findings uncovered while screening candidates for research participation. This can range from discovering high blood pressure (known as the “silent killer”) to extra sex chromosomes in people who volunteer as “healthy controls.” This raises the question of what is a clinically significant or “actionable” finding, and what information should be returned to the research participant. These types of questions are critical, especially because many research consent forms have historically stated that “no results will be returned.”
Collins O. Airhihenbuwa, PhD, MPH, is professor and head of the Department of Biobehavioral Health at Penn State University. The first RWJF Scholars Forum: Disparities, Resilience, and Building a Culture of Health was held last week. The conversation continues here on the RWJF Human Capital Blog.
As we address disparities and inequities, the challenge is to think about solutions and not simply defining the problem. Most would agree that health is the most important part of who we are. It is the first thing we think about in the morning when we greet one another by asking, “How are you this morning?” It is the last thing we think about at night when we wish someone a restful night.
What may be different is what health means to us and our families. This is why place and context are important. How we think about health and what we choose to do about it is very much influenced by where we reside. Our place and related cultural differences about health are less about right or wrong and more about ways of relating and meeting expectations our families and communities may have of us, whether expressed or perceived. More than that is the way we relate to what our place means in terms of how it is defined and subsequently how that definition shapes how we define it for ourselves. In other words the ‘gate’ through which we talk about our place and ourselves is very important in having a conversation about who we are and what that means for our health.