Voice: Dr. Amal Trivedi

Dr. Amal Trivedi is a medical doctor who practices in several states, a researcher who has been published in the New England Journal of Medicine and a faculty member at Brown University.

“It’s an economic issue, certainly, but it’s also a moral issue. I mean, ideally what we’d like to see is that every member of society has a chance for living a healthy, productive life. And to the extent that we see certain racial and ethnic groups in our society have lower life expectancy or a higher chance of dying in the first year of their life, that’s something that’s deeply, deeply troubling …”

I think the two takeaway points that I have from looking at the health disparities’ literature is that first the causes of health disparities are multi-factorial. There are a lot of factors that account for racial disparities in various health conditions, and that they vary depending on what kind of health disparity you’re talking about, whether you’re talking about infant mortality or disparities from, say, heart disease or diabetes, vary between ethnic groups.

Dr. Amal Trivedi

Dr. Amal Trivedi

So there is not one over-arching cause. There are lots of causes. Most of the studies that I have looked at found that social determinants of health play a big role. So social determinants are things that are actually outside the health care system. Things like income, education, the kind of neighborhoods that people live in, whether they are neighborhoods of deprivation, or neighborhoods of affluence, the kind of housing conditions that people live in. That these factors outside of the healthcare system actually have a big impact on disparities in health outcomes. And then the final piece is that healthcare plays a role – having basic access to preventive care to care for chronic conditions is important in reducing health disparities. Those are some of the big, sort of over-arching points. You know, it’s a very complicated issue that has many causes.

There’s been hundreds – perhaps thousands – of studies that have looked at disparities in health; and essentially every area where we have looked we have found significant racial and ethnic disparities in health. Racial and ethnic health disparities do exist, they have continued, and in some cases they’ve gotten worse. I think that’s a very important message.

Take infant mortality. Infant mortality has improved for both white Americans and black Americans, but the gaps have persisted; the disparity has not narrowed – in fact, according to some studies, it’s widened over time. It is possible for all groups to do better but for the gaps to remain if the outcomes are improving among whites at a faster rate or even at an equivalent rate. If whites improve at a faster rate; then you may see that although all groups are doing better that the gaps are getting worse.

I think that it should be concerning because it takes a tremendous toll on the lives of racial and ethnic minorities who comprise an increasing proportion of our society, and that it’s – ideally what we’d like to see is good help for all groups, and we shouldn’t see differences by race or ethnicity. We should see – it’s in the interest of everyone to make sure that we’ve got good health outcomes for all members of our population, for all of our groups. And so that’s why it should be tremendously concerning. It’s a very important public health issue.

It’s an economic issue, certainly, but it’s also a moral issue. I mean, ideally what we’d like to see is that every member of society has a chance for living a healthy, productive life. And to the extent that we see certain racial and ethnic groups in our society have lower life expectancy or a higher chance of dying in the first year of their life, that’s something that’s deeply, deeply troubling, and we can do better. It’s an issue that everybody should be concerned about.

I think, actually, the Affordable Care Act has the potential to address some of these disparities, because it does a number of really important things. One is we know that racial and ethnic minorities are much less likely to have health insurance; and the preponderance of the literature is that you see suggests not having health insurance increases the chance of having a worse outcome. So, as part of the Affordable Care Act, if it’s fully implemented, there will be a dramatic expansion in insurance, and that would mean that people who don’t have insurance currently, and it’s a group that is disproportionately racial and ethnic minorities, would have access to quality healthcare. So that’s sort of one aspect. The other is that huge investments in prevention and racial and ethnic minorities disproportionately suffer from preventable illnesses. And so there are a lot of investments in improving preventive health, in terms of screenings for diseases that could be treated earlier, promoting smoking cessation. So those are things that could also impact disparities. The other is just how our health care system is organized, which is that we have a very segregated healthcare system, where a small number of providers account for a large proportion of all patient visits made by racial and ethnic minorities. And racial and ethnic minorities are more likely to be seen in safety net settings that are traditionally under-funded, and as part of the Affordable Care Act, there is a large investment in community health centers and other safety net institutions, where many racial and ethnic minorities are seen. And to the extent that we can improve care in those traditionally under-resourced communities and clinics, we can potentially impact disparities in health outcomes. So those are a few of the investments in the Affordable Care Act.

The final piece is that the providers who are our health workforce don’t reflect the diversity of the population; and by promoting opportunities for minorities to become physicians and other health providers, that we will – we’ve found in other studies providers that are African American, Hispanic, are more likely to serve populations that are underserved and minorities. So by investing in diversity of our health professions workforce, that that might also be another lever to ameliorate our health disparities.

There are a number of factors that are outside the healthcare system that are critically important in addressing health disparities. These are social determinants. I’m a physician and I see patients with diabetes and heart disease very commonly; and I always recommend diet and exercise – you know, lifestyle modifications. But boy, I’ll tell you, if you live in a neighborhood where it’s not safe to go out for a long walk, or you don’t have any grocery stores that sell fresh fruits and vegetables, it’s really difficult to do lifestyle modifications. So investing in healthy neighborhoods, and changing the built environment to promote healthier outcomes, that’s going to be a huge step in trying to address health disparities and improve health outcomes for folks who live in under-resourced areas. That’s something that’s not – you know, that’s not investing specifically in an aspect of the healthcare system, like a hospital or a clinic. But it’s trying to improve communities to make sure that we promote healthier lifestyles. So that’s, like I said, a social determinant that’s not strictly about health insurance or the use of healthcare.

What I’ve been sort of impressed by is just the diversity within groups. It’s hard to really come across one overarching cultural factor that explains the disparities. I’m sort of more struck by the diversity within certain groups that we lump together, I guess would be sort of my approach to it. And you know, I also practice in different areas of the country, and what may drive disparities, say, in California, might be very different than in another – somewhere in the northeast, or between rural and urban. I work at the VA, and so we see there are parts of the country where remoteness is actually a really important factor, of being far away from the nearest clinic. In urban areas, there might be a hospital or a clinic that’s close by, but there may not be the coverage to actually use it. We live in a really diverse country and a very big country. So something that’s unique to Colorado may not translate to other states. And so that’s why it’s important for each of the different areas to track disparities. And that would be sort of the … additional point that I would like to make, which is just how important it is to measure locally. A lot of the studies that we have look at national disparities, but if you look within your own community, or say even as granular as your own patient practice, you might find that the disparities are a lot different than what’s observed nationally. And so local measurement is really key. And you really can’t improve anything that you don’t measure. So we need that kind of granular detail to see are the things that we’re doing locally, are they having an impact?

If you look nationally at infant mortality, the rates for African Americans are more than double that for whites. I find that deeply concerning. You know, the rates have improved for both groups, but they’re still sharply unequal, deeply unequal, and we can do better as a society. So there’s a moral case to be made that disparities are unacceptable, and that as a society we can make changes to make sure that everybody has a good opportunity to lead a healthy, productive life, and when we do that everyone benefits.

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