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TODAY'S CLINICAL CENTER GRAND
ROUNDS.
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PRESENTATION.
AS PART OF THE NATIONAL MINORITY
HEALTH MONTH, DR. PEREZ-STABLE,
WHO WORKS ON PROGRAMS TO
RESEARCH AND ADVANCE KNOWLEDGE
AND UNDERSTANDING OF HEALTH
DISPARITIES, IDENTIFIES
MECHANISM TO REDUCE HEALTH
DISPARITIES AND DEVELOPS
EFFECTIVE INTERVENTIONS TO
REDUCE HEALTH DISPARITIES IN
COMMUNITIES AND CLINICAL
SETTINGS.
DR. PEREZ-STABLE EARNED HIS
BACHELOR IN ARTS AND MEDICAL
DEGREE FROM THE UNIVERSITY OF
MIRROR IMAGE AMILLIO AND
COMPLETE RESIDENCY IN PRIMARY
CARE AND INTERNAL MEDICINE AND
FELLOWSHIP IN INTERNAL MEDICINE
AT THE UNIVERSITY OF CALIFORNIA
SAN FRANCISCO WHERE HE BECAME A
PROFESSOR OF MEDICINE AND A
CHIEF OF DIVISION OF INTERNAL
MEDICINE OR REMAINED CLINICALLY
ACTIVE IN PRIMARY CARE INTERNAL
MEDICINE AND SUPERVISING AND
TEACHING STUDENTS AND RESIDENTS.
DR. PEREZ-STABLE JOINED NIMHD IN
2015 AND CHARTED THE
EN--STRATEGIESITUTES POSITION ON
THE CUTTING EDGE OF SCIENCE OF
MINORITY HEALTH AND HEALTH
DISPARITIES.
THROUGH THIS INSTITUTE, IT HAS
PRODUCED A COLLECTION OF
RESOURCES THAT GUIDE AND
FACILITATE AND PROMOTE HEALTH
EQUITY.
RECOGNIZED AS A LEADER IN LATINO
HEALTHCARE AND DISPARITIES
RESEARCH, DR. PEREZ-STABLE HAS
HAD 3 DECADES OF RESEARCH ON
SMOKING CESSATION AND TOBACCO
CONTROL IN THE LATIN POPULATION
AND THE CLINICAL STUDIES,
SUPPORTING RESEARCH ON MINORITY
AGING AND CLINICAL AND COMMUNITY
SETTINGS AND AADDRESSING
RESEARCH QUESTIONS, CLINICAL
QUESTIONS SUCH AS HYPERTENSION,
ASTHMA, DIABETES AND DEMENTIA.
DR. PEREZ-STABLE HAS PUBLISHED
OVER 300 PEER REVIEWED ARTICLES
AND CONTINUOUSLY FUNDED BY THE
NIH WHILE HE WAS THE DIRECTOR OF
THE UCSF CENTER FOR DIVERSE AND
AGING COMMUNITIES WHICH IS
FUNDED BY THE NATIONAL
EN--STRATEGIESITUTE OF AGING AS
WELL AS WHEN HE WAS DIRECTOR OF
THE UCSF MEDICAL EFFECTIVENESS
RESEARCH CENTER FOR DIVERSE
POPULATIONS.
HE HAS BEEN A CAREER MENTOR PER
MANY STUDENTS, RESIDENTS AND
FACULTY, RESEARCH MENTOR FOR
OVER SEIVET MINORITY
INVESTIGATORS ANDA AN ELECTED
MEMBER OF THE NATIONAL ACADEMY
OF MEDICINE AND NATIONAL ACADEMY
OF SCIENCE AS WELL AS AMERICAN
SOCIETY OF CLINICAL
INVESTIGATION.
THE TIELT OF THIS PRESENTATION
TODAY IS SCIENCE AND MINORITY
HEALTH AND HEALTH DISPARITIES
RESEARCH.
PLEASE JOIN ME IN WELCOMING
DR. PEREZ-STABLE.
THANK YOU.
>> THANK YOU.
[ APPLAUSE ]
>> SO THANK YOU TOM FOR THAT
KIND INTRODUCTION, IT'S NICE TO
BE IN A CLINICAL CONTEXT, EACH
THOUGH I'M NOT GOING TO SAY A
WHOLE LOT ABOUT CLINICAL ISSUES,
A LITTLE BIT IN THIS TALK AND I
APPRECIATE THE ACKNOWLEDGMENT OF
MINORITY HEALTH MONTH, IT'S BEEN
BUSY.
WE JUST HOSTED DR. LOU SULLIVAN
ON MONDAY FOR SORT OF AN ORAL
HISTORY SESSION AND DR. SULLIVAN
IS 90 YEARS OLD AND I ONLY HOPE
TO BE AS WELL AS HE WAS ON
MONDAY WHEN I GET TO 90.
SO I LIKE TO START THIS TALK
ABOUT SAYING A FEW THINGS ABOUT
WHAT CAN WE DO WITH SCIENCE TO
REDUCE HEALTH INIQUITIES.
I WILL START WITH THE
STANDARDIZED MEASUREMENT OF
SOCIAL AND DEMOGRAPHIC
POPULATIONS THAT SHOW HOW
BEHAVIORIAL RESEARCH AND--THIS
IS A NO BRAINER FOR CLINICAL
SCIENTISTS BUT IN CLINICAL
SCIENCE WE DON'T DO THAT AS WELL
AND IN CLINICAL CARE, WE HAVE
NOT.
IT HAS GOTTEN A LOT MORE
TRACTION TO THINK ABOUT SOCIAL
DETERMINANTS OF HEALTH IN
EVALUATING HOW YOUR PATIENT IS
DOING AND CERTAINLY, IT STARTS
WITH STANDARDIZED DEMOGRAPHICS
AND I WILL COME BACK TO THIS.
WE NEED MORE EMPHASIS ON DATA
SCIENCE, DISCOVERY THROUGH DATA
SCIENCE, BIG DATA BECAUSE WE'RE
MOVING INTO A WORLD WHERE MORE
AND MORE DATA WILL BE AVAILABLE,
NOT JUST FROM THE ELECTRONIC
HEALTH RECORD AND TRYING TO
HARMONIZE THOSE AND MAKE THEM
USEABLE FOR RESEARCH AND CARE,
BUT ALSO IN POPULATION HEALTH,
WITH SURVEYS AND OTHER KINDS OF
DATA, SPATIAL DATA AS WELL AS
SURVEYS THAT ARE OFTEN DONE OR
DATA THAT ARE COLLECTED FOR
OTHER PURPOSES SUCH AS CLIMATE
OR DISTRIBUTION OF CERTAIN
BUSINESSES.
WE NEED TO BE AN ENGINE FOR
PROMOTING DIVERSITY AND TGF BETA
AND CLINICAL WELCOMER FORCE
DESPITE THE CHALLENGES THAT
EXIST AND I WILL SHOW YOU DATA
TO SUPPORT SOME IM PERICAL
EVIDENCE TO SUPPORT WHY THIS IS
GOOD AT REDUCING INIQUITIES AS
WELL AS WHERE THE STATE OF THE
FIELD IS TODAY.
THE PANDEMIC REALLY MADE
COMMUNITY ENGAGEMENT HIGHLIGHTED
AS AN IMPORTANT RESEARCH
PLATFORM IN WHICH TO MAKE CHANGE
IN OUR SOCIETY AND I BELIEVE
THAT IN NIH THERE IS NOW MORE OF
A COMMITMENT TO CONTINUE THIS
AND I WILL COME BACK TO THIS AS
WELL.
I WOULD ARGUE THIS IS AN
ESSENTIAL COMPONENT OF ANYTHING
WE DO IN HUMAN RESEARCH.
AND FINALLY, WE NEED TO
IMPLEMENT WHAT WE KNOW AND
ESPECIALLY IN THE CONTEXT OF
PROMOTING EQUITY.
WE KNOW HOW TO TREAT
HYPERTENSION, WE KNOW HOW TO
KROAT DIABETES, AT LEAST IN
80-85% OF THE POPULATION, IT
SHOULD BE MANAGED WELL AND YET
THE GROUPS THAT HAVE THE LEAST
WELL CONTROL IN THESE 2 CHRONIC
CONDITIONS ARE PEOPLE WHO ARE
DISADVANTAGED IN SOME WAY,
EITHER POOR OR BY RACE
ETHNICITY.
NOW, NIMHD HAS THE
RESPONSIBILITY OF DESIGNATING
POPULATIONS WITH HEALTH
DISPARITIES, THAT IS MY ROLE AS
THE DIRECTOR, THE AUTHORITY FROM
CONGRESS IN THE TOP 3 BULLETS
CAME IN OUR ORIGINAL
LEGISLATION, SO RACIAL AND
ETHNIC MINORITY POPULATIONS
WHICH IS NOT A STATIC FIELD, SO
I WILL COME BACK TO, POOR PEOPLE
OF ANY RACE AND ETHNICITY ACROSS
THE COUNTRY, UNDERSERVED RURAL
RESIDENTS, WE HEARD FROM
DR. SULLIVAN ABOUT HOW THAT CAME
ABOUT IN THE PROCESS OF CONGRESS
IN 2000 AND SEXUAL AND GENDER
MINORITIES AND PERSONS WITH
DISABLES ARE DESIGNATED
POPULATIONS THAT I HAD THE HONOR
TO DECLARE THE SGM COMMUNITY IN
THE YEAR 2016 AND PERSON WITH
DISABILITIES JUST LAST
SEPTEMBER.
A UNIFYING FACTOR FOR ALL THESE
POPULATIONS IS A CERTAIN AMOUNT
OF SOCIAL DISADVANTAGE THAT
EXISTS FROM BEING SUBJECT TO
DISCRIMINATION OR RACISM, AND
FROM BEING UNDERSERVED IN
HEALTHCARE IN SOME WAY.
NOW, IN HEALTH DISPARITIES
RESEARCH OR SCIENCE, WE BELIEVE
THAT RACE AND ETHNICITY AS A
SELF-IDENTIFIED SOCIAL
CONSTRUCT, AND SOCIOECONOMIC
STATUS HOWEVER IT IS MEASURED,
WHETHER IT BE BY INCOME OR
EDUCATION OR OTHER METRICS,
REALLY HAVE THE FUNDAMENTAL
DRIVERS OF HEALTH DISPARITIES IN
ALL POPULATIONS, AND IN OUR
SCIENCE.
THIS INTERSECTIONALITY OF RACE
AND ETHNICITY, SOCIOECONOMIC
STATUS, AGE, GENDER WITH RURAL
POPULATIONS, SEXUAL GENDER
MINORITY AT THAT TIMEUS AS WELL
AS PEOPLE WITH DISABLES ARE
CRITICAL WAYS TO LOOK AT THIS IN
OUTCOMES AND FOR THIS YOU OFTEN
NEED LARGE SAMPLE SIZES OR
FOCUSED STUDIES JUST ON THESE
POPULATIONS.
WE BELIEVE THAT APPLYING THIS
INTERSECTIONALITY LENS AS OUR
SOCIETY HAS BECOME MORE COMPLEX
TO ALL DEMOGRAPHIC FACTORS AND
TO ALL CLINICAL CONDITIONS ARE
WORTH WHILE THINKING ABOUT AND
DOING TO THE POINT OF
MEASUREMENT.
SO IF YOU DON'T ASK, YOU DON'T
KNOW, SO MEASURING THEM IN A
STANDARDIZED WAY BECOMES
IMPORTANT.
I ALSO--TRYING TO MOVE OUR
INSTITUTE AND THE FIELD TO STOP
COMPARING EVERYTHING TO WHITE
AMERICANS, TO SAY, WELL, THIS IS
AN ODDS RATIO OF 2.1 COMPARED TO
WHITES.
NOW WE SHOULD HAVE ASPIRATIONAL
GOALS WHERE EVERYONE SHOULD BE
AT AND THEN, SEE HOW WELL,
DIFFERENT GROUPS ARE IN
ACHIEVING THAT.
ON THE 1 HAND, WHITE AMERICANS
WILL NOT BE THE MAJORITY
POPULATION IN THE UNITED STATES
PROBABLY WITHIN THE NEXT 15 TO
20 YEARS, BASED ON DEMOGRAPHIC
PROJECTIONS, SECOND POINT IS
THAT THERE ARE SUBPOPULATIONS,
SPECIFICALLY LATINOS AND ASIANS,
WHO ACTUALLY OFTEN HAVE BETTER
HEALTH OUTCOMES THAN WHITES, SO
WE NEED TO THINK, MOVE AWAY FROM
THAT COMPARISON AND COMPARE TO
GOALS.
NOW,-ETHNICITY QUESTIONS JUST
CHANGED.
THOSE OF YOU WHO LOOK AT THE
FEDERAL REGISTER IN MARCH, SO
JUST LAST MONTH BECAME OFFICIAL
RULE FROM THE OFFICE OF
MANAGEMENT AND BUDGET, AND THE
CHIEF STATISTICIAN OF THE UNITED
STATES MADE THE DECLARATION THAT
THESE HAVE CHANGED NOW THIS HAS
BEEN IN DEVELOPMENT FOR ABOUT 2
YORES.
IT WAS ACTUALLY PREVIOUSLY
APPROVED IN THE YEAR 2016 BUT
NEVER REACHED THE STAGE OF RULE
AND WITH THE NEW ADMINITRATION
IN 2017, IT WAS MOSTLY SET
ASIDE, NOT ENTIRELY BUT MOSTLY
SET ASIDE EMPLOY SO THE FIRST
THING TO NOTE IS THAT THE CENSUS
ALWAYS ASKED A 2 PART QUESTION,
MANY PEOPLE INCORPORATED THIS,
WHAT IS YOUR ETHNICITY, THERE
WAS 1 ETHNICITY IN THE WORLD,
HISPANIC, NONHISPANIC, SO YOU
WERE IDENTIFIED AS BEING
HISPANIC LATINO OR NONHISPANIC
LATINO, AND THEN YOU ASK ABOUT
RACE, THAT'S OVER, THAT'S NO
LONGER THE RECOMMENDATION OR
REQUIREMENT I SHOULD SAY FOR
FEDERAL ENTITIES IS TO DO THESE,
1 QUESTION, HOW DO YOU IDENTIFY
YOURSELF AND THEN YOU HAVE 7
OPTIONS LISTED HERE IN THE
VIOLET COLOR SO WHITE, PLAQUE OR
AFRICAN AMERICAN, AMERICAN
INDIAN OR ALASKA NATIVE, ASIAN,
PACIFIC ISLANDER, HISPANIC OR
LATINO, AND MITTED EASTERN AND
NORTH AFRICAN.
AND IF YOU USE THIS TERMINOLOGY,
IT'S JUST WHAT THE CENSUS WILL
USE.
WE WILL THEN GET CLOSER TO
STANDARDIZED TERMINOLOGY IN HOW
WE REFER TO RACIAL AND ETHNIC
POPULATIONS IN THE UNITED
STATES.
NOTICE 2 THINGS, THE MULTIRACIAL
OPTION, OR MORE THAN 2 RACES AS
IT WAS FRAMED BEFORE, IS NOT
THERE SO THEY WILL BUILD IN AN
ALGORITHM SO THAT IF YOU CHECK
ALL THAT,A MRI AND YOU CHECK ALL
IN THAN 1 BOX, YOU WILL BE
CONSIDERED MULTIRACIAL, AND EACH
OF THE CATEGORIES, I DIDN'T HAVE
THE SPACE IN THE SLIDE TO LIST
ALL THE COUNTRIES, THE 6 MOST
COMMON HERITAGE COUNTRIES ARE
LISTED SO THAT THIS MORE
DETAILED SECONDARY DATA WILL
ALSO BE REQUIRED.
SO IF YOU'RE WHITE, IT WILL
LIST, ENGLAND, GERMANY, ITALY,
ET CETERA AND IF YOU'RE PLAQUE
OR AFRICAN AMERICAN, IT WILL
LIST CERTAIN COUNTRIES IN
AMERICA AND THEN THE CARIBBEAN,
AND AMERICAN INDIANS, TRIBES,
ASIAN INDIAN, ET CETERA AND
AMONG LATINOS, MEXICO, PUERTO
RICO, CUBA EL SALVADOR,
GUATEMALA ARE THE MOST COMMON
COUNTRIES LISTED BUT THERE'S
ROOM TO WRITE IN OTHER.
THE OTHER MAJOR CHANGE IS THE
ADDITION OF MIDDLE NORTHEASTERN
AND AFRICAN.
IT HAD BEEN PROPOSED AND
ADVOCATED FOR FOR SOMETIME AND
IT IS NOW OFFICIALLY A CATEGORY
IN THE FEDERAL REQUIREMENTS OF
COLLECTION OF DATA ON RACE AND
ETHNICITY AND THIS IS KNOWN AS
SP15, IT WAS ORIGE NAWILLLY FROM
1997, THIS IS THE SECOND TIME
IT'S BEEN CHANGED, DATING BACK
TO 1977.
SO WHAT IS RACE AND ETHNICITY
MEAN IN FIRST OF ALL, WE--YOU
KNOW--THERE'S A GENERAL
CONSENSUS AT NIH AS WELL, ACROSS
THE HEALTH OF RESEARCHERS THAT
THIS IS A SELF-IDENTIFIED SOCIAL
CONSTRUCT.
IT DOES HAVE APPLICATION
GLOBALLY.
IN A COUNTRY LIKE THE UNITED
STATES, WE GENERATED THE
CATEGORIES AS YOU SAW, BASED ON
WHAT THE POPULATION DEMOGRAPHICS
ARE, OTHER COUNTRIES MAY HAVE
DIFFERENT CATEGORIES, OR NAME
THEM DIFFERENTLY, LIKE IN THE
UNITED KINGDOM, AND IN LATIN
AMERICA BUT THIS IS SOMETHING
THAT APPLIES GLOBALLY UNTIL THE
HUMAN SPECS ADD MIXES ENOUGH,
WHERE THERE'S REALLY NO
DIFFERENCES BECAUSE EVERYBODY'S
MIXED WITH EACH OTHER, AND IT
HASN'T HAPPENED AND IT WON'T
HAPPEN IN MY LIFETIME ALREADY,
THIS CONSTRUCT WILL CONTINUE TO
HAVE SOCIAL AND DEMOGRAPHIC
MEANING AND BY CONSEQUENCE
MEANING ON HEALTH.
IT'S BASED ON THE GEOGRAPHIC
ORINIGEIN OF HUMANS OUT OF EAST
AFRICA HOW THEY MIGRATED OUT TO
PARTS OF THE GLOBE AND
SUBSEQUENTLY MIX BEGINNING MOST
DRAMATICALLY AROUND 1500 WITH
THE EUROPEAN COLONIZATION OF THE
AMERICAS.
BUT IT HAS BEEN GOING ON AT A
SLOW RATE ALL FROM THE BEGINNING
OF THE HUMAN DEVELOPMENT, AND
ETHNIC GROUP MAY NOT SHARE
PHENOTYPES, SO AN ETHNIC GROUP
COULD BE BASED ON GEOGRAPHY, ON
CULTURAL, ON CULTURE, ON
RELIGION, ON AFFINITYS ARE THAT
ARE NOT PHENOTYPICALLY
ADEPTIFIED SO LATIN AMERICA IS A
GOOD EXAMPLE, LATIN AMERICA IS A
MIX OF THE INDIGENOUS PEOPLE,
THE EUROPEAN COLONIALISTS AND
THE AFRICANS WHO WERE BROUGHT
OVER AS SLAVES OF WHICH ABOUT
2/3RDS WENT ACTUALLY TO THE
CARIBBEAN AND SOUTH AMERICA
PRIMARILY, BRAZIL AND THE REST
CAME TO THE UNITED STATES
MOSTLY.
THERE ARE BIOLOGICAL FACTORS,
THAT CAN BE MEASURED HERE, MOST
OF THEM ARE ON GENETIC ANCESTRY,
BUT ALSO METABOLIC PATHWAYS AND
CLEARLY SHARED BEHAVIORS, CLUOF
THEICAL CLUSTERS THAT BE CREATED
AND WE BELIEVE THAT THIS IERK
DENTITY OF RACE AND ETHNICITY,
REFLECTS IN MANY WAYS THE LIVED
EXPERIENCE AND IN THE UNITED
STATES IN PARTICULAR, THIS IS
SIGNIFICANT FOR RACE
DISCRIMINATION EXPRESSION AND AS
WELL AS IN OTHER CONTEXT POVERTY
OR ADVERSITY IN LIFE, HERE'S A
FEW EXAMPLES OF HOW RACE AND
ETHNICITY MATTER.
THIS IS DATA FROM THE FLOABAL
BURDEN OF DISEASE U.S. HEALTH
DISPARITIES PROJECT WHICH IS AN
INTRAMURAL PROJECT OF THE
NATIONAL INSTITUTE OF MINORITY
HEALTH AND HEALTH DISPARITIES,
WE'VE SEEN THIS AND KNOWN IT IN
THE CDC SIMILAR PUBLISHED DATA
AROUND THE SAME TIME.
WE KNOW LATINOS HAVE THE LONGER
LIFE EXPECTANCY FOR AT LEAST 20
YEARS, THIS IS NOT AN ARTIFACT,
THIS IS REAL, THIS HAS BEEN VERY
CONSISTENT DATA NOW FOR ABOUT 30
YEARS AND LAT TIN OS ARE
HETEROGENIUS BUT ASIANS ARE EVEN
MORE HETEROGENIUS AS A GROUP AND
WE SEE THIS PHENOMENA EMPLOY AND
WE SEE WHITES IN THE MIDDLE,
CLOSE TO THE GREEN TOTAL LINE,
AND YOU NOTICE THE DIRE
SITUATION THAT AMERICAN INDIANS
AND ALASKA NATIVES HAVE EVEN
THOUGH THERE'S A TREMENDOUS
AMOUNT OF UNCERTAINTY AROUND
THESE ESTIMATES GIVEN BOTH THEIR
SMALL SIZE AND THE
MISCLASSIFICATION CHALLENGES
THAT EXIST WITH AMERICAN INDIAN
AND ALASKA NATIVES FREQUENTLY
MIXED WITH OTHER POPULATIONS.
AND THEN AFRICA AMERICANS NOTICE
IMPROVING ALONG WITH THE REST OF
THE GROUPS VERY SLOWLY NOW SINCE
2010 AND PROJECTIONS ARE THAT
THESE WILL CONTINUE TO SLIGHTLY
IMPROVE, THIS IS PRECOVID BY THE
WAY.
WE ALSO FUNDED AN ANALYSIS OF
WHAT WE CALL THE ECONOMIC BURDEN
OF RACIAL, ETHNIC AND RACIAL
HEALTH INIQUITIES IN THE U.S.
ISSUES THESE FACTORED IN NOT
JUST PREMATURE MORTALITY BUT
ALSO EXCESS MEDICAL CARE
EXPENDITURES AND LOSS LABOR
MARKET PRODUCTIVITY AND USED
NATIONAL DATA FOR NATIONAL
CENTER FOR MORTALITY DATA,
BEHAVIORIAL RISK FACTOR SURVEY
AND THE MEDICAL EXPENDITURE
PANEL SURVEY WHICH IS A COHORT
STUDY FROM THE AHRQ, AND
COMPARED TO A HEALTH EQUITY
GOAL, WHERE SHOULD WE BE AND USE
HEALTHY PEOPLE 2030 AS
DEVELOPING WHAT WOULD BE THE
HEALTH EQUITY GOALS AND YOU SEE
THE ECONOMIC BURDEN FOR RACIAL
AND ETHNIC MINORITY GROUPS IN
2018, 1 YEAR, 451 BILLION
DOLLARS EMPLOY NOW THE NIH
BUDGET IS A LITTLE OVER 10% OF
THAT AND IF WE LOOK AT IT BY
EDUCATIONAL LEVEL, WE CAN SEE,
AND COMPARE IT TO COLLEGE
GRADUATE WE SEE THE BURDEN GO
ALMOST TO A TRILLION DOLLARS, SO
THESE ARE SOCIAL FACTORS THAT
CAN BE INTERVENED UPON OR
FOCUSED ON THAT CAN MAKE A
DIFFERENCE IN POPULATION HEALTH
FOR OUR COUNTRY.
SO BACK TO THE MEASUREMENT ISSUE
IS WHAT SHOULD WE DO IN A
CLINICAL CONTEXT?
NOW RESEARCHERS WHO DO THIS
WORK, IN DISPARITIES OFTEN IN
OTHER CONTEXT, KNOW HOW TO DO
THIS BUT WE DON'T DO A GREAT YOB
IN A CLINICAL CONTEXT OF GETTING
AT THE SOCIAL DETERMINANTS OR
DEMOGRAPHIC FACTORS WITH A FEW
EXCEPTIONS.
OUTSIDE OF NIH, ALL THE PATIENTS
WHO COME TO A CLINICAL SETTING
WILL KNOW THEIR INSURANCE,
RIGHT, AND WILL USUALLY KNOW
THEIR SEX AND USUALLY KNOW THEIR
AGE BUT AFTER THAT IT DROPS OFF
SIGNIFICANTLY, SO THE OMB CENSUS
CATEGORIES FOR RACE ASK
ETHNICITY, I WOULD STRONGLY
RECOMMEND THAT WE USE IN A
STANDARDIZED WAY AND IT SHOULD
BE ASKED IN A STANDARDIZED WAY,
IT SHOULD BE LEFT TO OH, YOU
KNOW YOU LOOK LIKE THIS AND LEFT
UP TO A FRONT DESK, IT SHOULD BE
SELF-REPORTED IN A STANDARDIZED
WAY.
OTHER THINGS LIKE EDUCATIONAL
ATTAINMENT IS A CRITICAL
PREDICTER OF HEALTH.
IT'S ALSO A PREDICTER OF HOW YOU
COMMUNICATE WITH SOMEONE.
I WOULD ARGUE RACE AND ETHNICITY
ARE AS WELL, SO FOR THE
CLINICIAN TO KNOW WHO IS MY
PATIENT, WHERE ARE THEY COMING
FROM, NOT JUST WHO I THINK THEY
ARE, BUT KNOW WHERE THEY'RE
COMING FROM, THIS IS PART OF
THAT INITIAL UNDERSTANDING THAT
WE'RE NOT AS CLINICIANS CARING
FOR DISEASES, WE'RE ACTUALLY
CARING FOR PEOPLE WITH THE
CONDITIONS ORIGINAL WHO ARE
HEALTHY OR COMING FOR PREVENTION
INTERVENTIONS.
MANY OTHER FACTORS, SEXUAL
ORIENTATION, GENDER IDENTITY,
DISABILITY STATUS, DO WE ISSUE
IN THAT ON THE BASIS OF FUNCTION
OR CATEGORY, DO WE AUTOMATICALLY
SAY YOU HAVE A DISABILITY IF YOU
HAVE HAD A PARTICULAR CHRONIC
DISEASE PROBLEM OR DO WE ASK A
STANDARDIZED SET OF QUESTIONS
BASED ON FUNCTION, MOSTLY
AROUND, CAN YOU CARE FOR
YOURSELF AND CAN YOU CARE FOR
YOURSELF, TAKE CARE OF YOURSELF
IF YOU'RE ALONE IN TERMS OF
FINANCES AND SHOPPING AND
COOKING AND THINGS OF THAT TYPE,
MUCH WHAT THE GERIATRICIANS HAVE
BEEN DOING FOR QUITE SOMETIME TO
REALLY EVALUATE THAT STATUS.
WE ALSO NEED TO KNOW WHERE
PEOPLE LIVE AND A COMMUNITY
MEASURE IS IMPORTANT, NOT
KNOWING YOU KNOW WHEN I REMEMBER
NOT KNOWING AS A CLINICIAN AT
UCSF, STARTING AS A RESIDENT,
THERE WOULD BE PATIENT WHO IS
TAKE 3 BUSES TO GET TO UCSF
WHICH IS IN ANOTHER NEIGHBORHOOD
IN SAN FRANCISCO, AND KNOW WHERE
THEY LIVE, WHAT IS THE MISSION
DISTRICT LIKE, WHAT IS THE
POPULATION LIKE?
AND DOING A COMMUNITY MEASURE
MAY NOT BE THAT DIFFICULT IF WE
USED EXACT ADDRESS, WE CAN
ACTUALLY IMPUTE DATA FROM CENSUS
TRACKS, WE DON'T DO THAT EACH
FOR OUR RESEARCH NECESSARILY,
BUT THIS IS A DIRECTION I THINK
THAT WE HAVE THE CAPABILITY OF
DOING THIS AND THE TECHNOLOGY TO
DO IT.
NOW ACCESS TO FOOD, JOBS,
TRANSPORTATION, HOUSING, GREEN
SPACE, SAFETY, SORT OF THE
STRUCTURAL SOCIAL DETERMINANTS
OF HEALTH ARE ALL AVAILABLE FROM
CENSUS IF WE IMPUTE IT AND THERE
ARE RESEARCH EFFORTS THAT ARE
WORKING ON THINGS, CREATING
THINGS LIKE THE EXPOSOME THAT
WOULD INCLUE THESE KINDS OF
THINGS AS WELL AS PM2.5
EXPOSURE, AND OTHER FACTORS THAT
MATTER IN INFLUENCING HEALTH.
WE'VE COLLABORATED WITH
SCIENTISTS ACROSS NIH AND ACROSS
THE COUNTRY IN CREATING A
PORTFOLIO OF MEASURES THAT WE
CALL THE SOCIAL DETERMINANTS OF
HEALTH MEASURES COLLECTION, THE
WEB LINK IS ON THE SLIDE, WE
HAVE THE--OUR SYMBOL, OUR
WEBPAGE, I SHOULD SAY ON THE
PHOENIX TOOL KIT IS THE 3 LITTLE
HOUSES HERE AND WITHIN 2 CYCLES
OF REVIEW OF TRYING TO CREATE
THAT MEASURES, THAT HAVE BEEN
USED IN NATIONAL STUDIES OR WELL
VALIDATED FOR DIFFERENT
CONSTRUCTS.
MOST OF THE EFFORTS HAVE GONE TO
ADDRESSING ISSUES AROUND
MEASURING STRUCTURAL SOCIAL
DETERMINANTS AND THE 1S MOST
RECENTLY VETTED IN DECEMBER OF
2022 ARE LISTED ON THE SLIDE,
THINGS LIKE HEALTHCARE
COMMUNICATIONS, INTERNET ACCESS,
WATER QUALITY ACCESS, THERE ARE
ALSO A SET OF MEASURES THERE ON
DEMOGRAPHICS, THINGS LIKE
INDIVIDUAL SOCIAL DETERMINANTS,
THINGS LIKE FOOD INSECURITY,
HOUSING SECURITY, EVERY DAY
DISCRIMINATION KALE AND THOSE
MOSTLY HAVE BEEN BORROWED FROM
THINGS THAT EXISTS ON THE
WEBSITE OR NATIONAL STUDIES DONE
BY THE CDC, AND IT'S TIME
BECAUSE OF THE OMB CHANGES AS
WELL AS OTHER REASONS THAT WE
RESILIENCE VIEW THOSE AND UPDATE
THEM.
AND AND WE ALSO REGENERATED THE
STAFF AND THE WORKFORCE TO GUIDE
US AS TO WHERE ARE WE FUNDING,
WHAT ARE WE LOOKINGA THE AND I
WILL POINT OUT A COUPLE THINGS
HERE, FIRST THE MAIORITY OF THE
GRANTS THAT WE FUND AT NIMHD AS
WELL AS AT NIH ARE IN THIS
INDIVIDUAL COLUMN, EVEN AT OUR
INSTITUTE WHEN WE LOOK AT THIS,
WELL OVER HALF, YOU KNOW
3-QUARTERS OF THE GRANTS ARE
FOCUSED ON INDIVIDUALS.
IT'S HARDER TO DO RESEARCH IN A
SOCIETAL LEVEL OR EVEN A
COMMUNITY LEVEL, OR
INTERPERSONAL LEVEL, SO THAT'S A
DIRECTION I THINK WE'VE BEEN
TRYING TO NUDGE THE FIELD
TOWARDS THROUGH SPECIAL
ANNOUNCEMENTS.
IF YOU ASK ME WHAT'S THE CAUSAL
DIRECTION HERE OF HEALTH
DISPARITIES OR INIQUITIES, IT'S
PROBABLY MORE RIGHT TO LEFT OR
SOCIETAL TO INDIVIDUAL THAN IT
IS INDIVIDUAL TO SOCIETY.
THEN WE HAVE THE DOMAINS OF
INFLUENCE, THE EXPLOSION IN
INFORMATION ABOUT BIOLOGY, THAT
WE'VE KNOWN FOR THE LAST 25
YEARS BEGINNING WITH THE HUMAN
GENOME PROJECT, BEHAVIORIAL
ISSUES, PHYSICAL AND BUILT
ENVIRONMENT, THAT ALSO HAD AN
EXPLOSION IN THE LAST 25 YEARS
IN DATA AND IN SCIENCE AROUND
WHAT DOES IT MEAN TO LIVE IN
THIS NEIGHBORHOOD WHEN YOU HAVE
NO ACCESS TO FRESH FRUITS AND
VEGETABLES THAT ARE NOT
AVAILABLE UNLESS YOU HAVE A
MOTOR VEHICLE, YOU OWN A MOTOR
VEHICLE AND THERE'S REALLY POOR
PUBLIC TRANSPORTATION, SO,
IMAGINE, WE TELL THAT PATIENT,
WELL, YOU HAVE DIABETES, YOU
HAVE TO BUY THIS KIND OF FOOD
AND THEN THEY CAN'T ACCESS IT.
AND THEN THE SOCIAL CULTURAL
ENVIRONMENT AND SEE THE
HEALTHCARE SYSTEM, I WANTED TO
MAKE SURE THAT THAT WAS INCLUDED
FIRST BECAUSE I USED TO PRACTICE
PRIMARY CARE AND INTERNAL
MEDICINE AS YOU HEARD AND I KNOW
THIS MATTERS TO PEOPLE'S HEALTH
AND SECOND THE HEALTHCARE--THE
HEALTHCARE SETTING CAN BE A
PLACE WHERE WE MAKE DISPARITIES
WORSE OR WE CAN REALLY HELP TO
MITIGATE THEM AND THE EXAMPLE OF
CONTROLS CHRONIC DISEASES IS 1.
NOW I WILL GIVE YOU SOME
RESEARCH EXAMPLES OF THINGS WE
HAVE FUNDED THAT HAVE AND I
THINK IMPACTED HEALTHCARE, SO,
DURING COVID, WE DO A LOT OF
RAPID TURN AROUND FUNDING.
THIS WAS A PARTICULARLY CREATIVE
COMPETITORS ECTOMYOSIN THAT'S
ACTUALLY NIAID PICKED UP THIS
GRANT, IS VACCINE MESSAGING
PLATFORMS AND EMERGENCY
DEPARTMENT ANDS IT WAS DONE IN
SAN FRANCISCO IN THE
SAN FRANCISCO GENERAL HOSPITAL,
SO YOU SEE 500 ADULTS, EXPOSED
TO A 4 MINUTE VIDEO, FEATURING
RACE CONCORDANT PHYSICIAN AND 1
PAGE INFORMATIONAL FLYER FOR
PATIENTS AND CLINICIANS AND
THERE WAS GREATER VACCINE
ACCEPTANCE AFTER EITHER HALF AN
OUR OR 6 HOURS AFTER THE ISHT
VENTION EXPOSURE AND GREATER
VACCINE UPTAKE, 30 DAYS AFTER
THE EMERGENCY DEPARTMENT VISIT
AND THERE WERE LARGER EFFECT
SIZE FOR LATINOS AND
PARTICIPANTS WITHOUT A PRIMARY
CARE PHYSICIAN FOR WHOM THEY
BEING ASK FOR QUESTIONS.
NOW WHEN WE LOOK BACK AT WHAT
HAPPENS DURING COVID, MANY
LESSONS CAN BE LEARNED BUT 1 OF
THE THINGS WE WERE ABLE TO DO IS
REALLY UNDERSTAND THE HUGE
DISPARITIES THAT EXISTED AT THE
BEGINNING IN MARCH AND APRIL OF
2020 THAT PERSISTED FOR A WHILE
AND THAT WE WERE ABLE TO, IF YOU
WISH, LEVEL THE PLAYING FIELD
FOR THE MOST PART BY THE FALL OF
2022.
THESE ARE COVID-19 ASSOCIATED
DEATHS IF 2020 AND 2021, AND THE
LIFE EXPECTANCY FOR FOR 2021 WE
WILL SEE THIS IMPACT, WE TALKED
ABOUT WO-3 YEARS OF LIFE
EXECANCY LOST FOR AFRICAN
AMERICANS, LATINOS, AMERICAN
INDIANS AND ALASKA NATIVES AND
YOU SEE WHY.
THE COVID ASSOCIATED DEATHS BY
RACE AND ETHNICITY, WERE DOUBLE,
TRIPLE IN THESE POPULATIONS
COMPARED TO ASIANS OR TO WHITES
AND WHITES WERE NOT EXACTLY
EXEMPT FROM HAVING EXCESS
MORTALITY IN CERTAIN PARTS OF
THE COUNTRY.
BY 2022, YOU SEE MUCH NARROWER
DIFFERENCES AND IN FACT, YOU SEE
THAT THE EXAMPLE OF LATINOS, NO
DIFFERENCE FROM WHITES, YOU SEE
AFRICAN AMERICANS, SLIGHTLY
HIGHER BY ABOUT 15-20%, NOT
TRIPLE THE DEATH RATES IN
AMERICAN INDIANS CONTINUE TO BE
SOMEWHAT HIGHER BUT AGAIN
MARKEDLY IMPROVED.
THIS WAS A TRIUMPH OF BOTH
FORMATION, MESSAGING TO THE
COMMUNITIES, THE MOBILIZATION OF
THE PROFESSIONALS, AND THE
COMMUNITY LEADERS AND ALL THE
DIFFERENT ACTIVITIES THAT NIH
WAS VERY MUCH INVOLVED WITH THAT
THE WHOLE DEPARTMENT OF HEALTH
AND HUMAN SERVICES AS WELL AS
THE COUNTRY WAS INVOLVED WITH.
TURNING TO CARDIOVASCULAR DEC,
THIS WAS A STUDY PUBLISHED A
YEAR AGO IN THE ANNALS OF
INTERNAL MEDICINE AND THIS IS
DISPARITIES AND STATIN FOR
PREVENTION OF CARDIOVASCULAR
DISEASE.
NOW IN MY OWN PERSONAL PRACTICE
AND IN READING THIS LITERATURE,
YOU KNOW 10 YEARS AGO, I WOULD
HAVE A HARDER TIME ARGUING FOR
PRIMARY PREVENTION USING A
STATIN, SO THIS IS MEDICALIZING
YOUR LIFE, TAKE A DRUG EVERY
NIGHT BECAUSE YOU WILL LIVE
LONGER AND THE BENEFIT WAS THERE
PROBABLY FOR MEN AUTOMATIC YOU
HAD TO KIND OF SCRATCH A LITTLE
BIT.
DEFINITELY NEVER CLEAR FOR WOMEN
IN MY MIND BASED ON RANDOMIZED
TRIALS BUT FOR SECONDARY
PREVENTION, SO IFFY WOO KNOW YOU
HAVE CORONARY DISEASE, YOU
HAVEN'T HAD ANYTHING HAPPEN TO
YOU YET BUT WE KNOW YOU HAVE
CORONARY DISEASE, THE DATA ARE
COMPELLING THAT YOU SHOULD BE ON
THIS DRUG AND WE SEE THAT FOR
AFRICAN AMERICAN WOMEN,
MULTIRACIAL MEN, WOMEN OF ANY
GROUP WERE LESS LIKELY TO DO IT,
THESE WERE BASED ON NATIONAL
HEALTH AND SURVEY, 2015 TO 2020.
SO TO ME THIS IS A SIGN THAT WE
KNOW IT WORKS, YET WE'RE NOT
IMPLEMENTING IT AND WE'RE OFTEN
NOT IMPLEMENTING IT IN THE MOST
DISADVANTAGED GROUP OR PERHAPS
IN THE CASE OF WOMEN,
FREQUENTLY, THEY DON'T GET HEART
ATTACKS, RIGHT IN IT'S ONLY MEN
AND THAT STEREOTYPE PLEEF
PERSISTS TO THIS DAY.
WE CAN ALSO ADJUST OR THINK
ABOUT HOW WE ADJUST RISK FACTORS
IN TERMS OF CARDIOVASCULAR
DISEASE MORTALITY, THIS IS AGAIN
DATA FROM THE NATIONAL HEALTH
AND NUTRITION EXAM NATION SURVEY
AND WHEN YOU SLEEP APNEA AND
OBESITYY BLACK BHIET DISPARITIES
CAN BE REDUCED IF YOU AJUST FOR
METABOLIC OR BEHAVIORIAL RISK
FACTORS WHETHER IT'S SMOKING,
DIABETES AND THESE OTHER SOCIAL
DETERMINANTS SUCH AS FOOD
INSECURITY AND UNEMPLOYMENT.
THE DEMOGRAPHIC AND HAVING LOWER
SOCIOECONOMIC STAT US, WE STILL
SEE CARDIOVASCULAR DEC
MORTALITY, HIGHER FOR AFRICAN
AMERICANS COMPARED TO WHITES AND
CERTAINLY A LATINOS AND A GROUP
OF OTHER RACE AND NHANES ARE
LOWER.
THIS PARTICULAR STUDY LOOKED AT
THE PERCUTANEOUS, AND THIS IS
USING LARGE DATA SETS,
PERCUTANEOUS CORON AREY
INTERVENTION AND WITH
CARDIOLOGISTS IN THE AUDIENCE, I
WON'T TELL YOU ABOUT THIS
LITERATURE BUT IT'S CLEAR THAT
IF SOMEONE'S HAVING AN ACUTE
THROMBOTIC EVENT IN THEIR
CORONARY ARTERY, THE FASTER WE
CAN GET TO THEM, THE FASTER
THEIR OUTCOME WILL BE, SO THIS
IDEA OF GETTING IT QUICKLY, THIS
ASSOCIATED WITH THE CORONARY
ISHT VENTION AS BECOME A
STANDARD BY WHICH WE CAN COMPARE
THE QUALITY OF CARE FOR THE
LEADING CAUSE OF DEATH IN THE
UNITED STATES, SO OBVIOUSLY AN
IMPORTANT CONDITION.
AND IN ALL PAYOR NONPUBLIC
DISCHARGE INFORMATION FROM
CALIFORNIA SO FROM 2006-2020 YOU
SEE THE SAMPLE SIZE OVER 600,000
PATIENTS WITH MYOCARDIAL
INFARCTION AND AJUSTING IT FOR
THEIR ZIP CODE, SO LOOKING AT
THEIR ZIP CODE TO GET THE AREA
DEPRIVATION INDEX, SO WHAT IS
THE FACTOR OF WHERE YOU LIVE,
YOUR COMMUNITY HAVE ON DO WITH
YOUR HEART ATTACK OUTCOME, YOU
WILL ASK?
WELL THIS IS DATA THAT SAYS THAT
AT THE END OF 1 YEAR, THE SAME
DAY, PERCUTANEOUS INTERVENTION,
3.1% AND 5.1% ABSOLUTE GREATER
LIKELIHOOD OF RECEIVING IT IF
YOUR AREA OF DEPRIVATION INDEX
WAS LOWER, SO YOU WERE WERE A
BETTER COMMUNITY IN EMERGING ITS
OF OVERALL MEASURES.
8 PERCENT LIKELIHOOD OF
RECEIVING PCI DURING
HOSPITALIZATION AND 2.1% LOWER
30 DAY MORTALITY AND EVEN AT 1
YEAR MORTALITY, A 3.9%, ABSOLUTE
LOWER, SO THIS IS I THINK GOOD
EVIDENT THAT THE SOCIAL
DETERMINANTS, YOUR STRUCTURAL
SOCIAL, YOUR COMMUNITY WHERE YOU
LIVE IN, REALLY MATTERS TO YOUR
HEALTH OUTCOME, SO THAT'S WHY, 1
OTHER REASON WHY CLINICIANS
SHOULD PAY ATTENTION, TOO, THIS
AN INTERESTING STUDY, A NEGATIVE
CLINICAL TRIAL, IT'S PERIDONTAL
DISEASE TREATMENT AFTER STROKE
OR TRANSIENT ESCHEMIC ATTACK, A
LOT HAS BEEN HYPOTHESIZED AND
WRITTEN ABOUT THE ROLE OF
CHRONIC INFLAMMATORY AND ORAL
INFLAMMATION IN THE ORAL CAVITY
PARTICULARLY FOCUSED ON
PERIDONTAL DISEASE AND HOW THEY
MAY PRECIPITATE THROMBOTIC
EVENTS IN THE CEREBRAL
VASCULATURE AS WELL AS IN THE
CORONARY ARTERIES AND THIS WAS A
STUDY THAT LOOKED AT PEOPLE OVER
18, HOSPITALIZED WITH A RECENT
ISOTOPE CHEEMIC STROKE OR TIA
AND HAD AT LEAST 5 NATURAL
TEETH, SIGNS OF MODERATELY
SEVERE PD.
AND THEY GOT INTENSIVE TREATMENT
FOR THE PERIDONTAL DEC A SIMPLE
POINT OF INTERVENTION WAS NOT IN
THE OPTIMAL PLACE, MAYBELET
STANDARD TREATMENTS HAVE GOTTEN
BETTER ON YOU NEED A MUCH LARGER
SAMPLE SIZE TO MAKE A DIFFERENCE
BUT THIS IS SOMETHING THAT
SHARE.
TURNING TO DIABETES AND
OUTCOMES, AGAIN, KIND OF OUT OF
THE BOX THINKING ABOUT HOW TO
IMPROVE DIABETES, CONTROL.
THIS IS FROM AN INVESTIGATOR WHO
WAS IN MILWAUKEE AT THE TIME AND
THIS DPROWP TOOK FINANCIAL
INCENTIVES, WITH TECH BASED
DIABETES EDUCATION INTERVENTION
TO FOCUS ON 60 AFRICAN
AMERICANS, SO IT WAS PROOF OF
CONCEPT STUDY, WITH TYPE 2
DIABETES AND IN POOR CONTROL.
THEY DIVIDED THE STRATIFIED THE
POOR CONTROL FROM 8-10% WHICH WE
WOULD ALL AGREE AND OVER 10%
WHICH IS REALLY POOR, AND THEN
RANDOMIZED TO FINANCIAL
INCENTIVES, ALL LIMITED TO $300,
SO THIS IS--THIS IS SUBSTANTIAL
BUT NOT A HUGE AMOUNT OF
FINANCIAL INCENTIVES, AND THEN
STUDIED THE DIFFERENT WAYS OF
GIVING THE FINANCIAL INCENTIVES,
SO THE FIRST MESSAGE IS THAT
DOING LOW FREQUENCY, MODERATE
FREQUENCY OR HIGH FREQUENCY
INSEBTIVES, YOU KNOW EVERYONE
DROPPED THEIR A1C, BUT YOU HAD A
SIGNIFICANT DROP IN A1C ALMOST
TO 8.1% OVER THE COURSE OF THESE
90 DAYS, 3 MONTHS OF TREATMENT
AND THIS IS A--SORT OF THE MODEL
OF DOING CASH INCENTIVES TO
PROBABLY INDUCE BEHAVIOR CHANGE
IN SOME WAYS OR PROVIDE ENOUGH
MONEY FOR HEALTHY FOOD, THE
EXACT MECHANISM IS UNCLEAR, BUT
IT CLEARLY IS ANOTHER APPROACH
THAT WOULDN'T NECESSARILY BE
SOMETHING WE WILL THINK ABOUT
FROM A CLINICAL SIDE, WE THINK
WELL, YOU NEED A SECOND DRUG OR
YOU NEED THIS OR YOU NEED TO
REALLY MODIFY YOUR DIET AND BUT
TO ACTUALLY FACILITATE THIS
THROUGH CASH INCENTIVES, THERE'S
A LOT OF DATA ON CASH INCENTIVE
INTERVENTIONS, MOSTLY IN THE LOW
AND MIDDLE INCOME COUNTRIES IN
OTHER KINDS OF ACTIVITIES, BUT
INCORPORATING MORE OF THIS INTO
HEALTH, THIS IS--A VARIATION ON
WHAT--THIS IS ALSO KNOWN AS
BEHAVIORIAL ICNATIONAL LIBRARY
OF MEDICINICS IS AN IMPORTANT 1.
AND THEN THE WHOLE IDEA OF DID
NEIGHBORHOOD MATTER AND DOES
NEIGHBORHOOD COHESION BUFFER
FOOD INSECURITY AND TYPE 2
DIABETES, AND AGAIN, SECONDARY
NATIONAL HEALTH DATA ANALYSIS,
LATINOS WITH LOW FOOD SECURITY,
HAD 2 TIMES THE ODDS OF HAVING
DIABETES COMPARED TO THOSE WHO
WERE FOOD SECURE.
SO IN THIS FIELD OF THINKING
ABOUT HOW YOU FACTOR IN ALL
THESE DIFFERENT THINGS, WE
ACTUALLY NEED BETTER WAYS OF
MEASURING SOME OF THESE
CONCEPTS, SO WHAT IS
NEIGHBORHOOD COHESION, DO WE
REALLY KNOW HOW TO MEASURE THAT,
WE USE SOME QUESTIONS ABOUT WHAT
WE CALL NEIGHBORHOOD COHESION IN
TERMS OF SAFETY OR DO YOU KNOW
YOUR NEIGHBORS, DO YOU INTERACT
WITH YOUR NEIGHBORS, DO YOU HAVE
A COMMUNITY CONNECTION WHERE YOU
GO TO MEET WITH PEOPLE IN YOUR
NEIGHBORHOOD, WHAT IS YOUR
NEIGHBORHOOD, WE ASK PEOPLE,
TAKE A GOOG EPI-BLAST MAP AND
DRAW A LINE AROUND WHERE YOUR
NEIGHBORHOOD IS.
IT'S A GOOD EXERCISE TO GO THRU
AND PEOPLE ARE OFTEN USING THEIR
NEIGHBORHOOD WHERE THEY SHOP,
VISIT THEIR CHURCH OR OTHER
ACTIVITY WITH THEIR WORK, AND IT
DOES VARY ACCORDING TO WHETHER
OR NOT, WHAT KIND OF A CITY YOU
LIVE IN OR IN A MORE RURAL OR
SUBURBAN AREA.
AND SO THINKING IN THESE TERMS,
I THINK IS A DIFFERENT DIRECTION
FOR CLINICAL RESEARCH, THAT
NEEDS TO HAPPEN AS WE GET BETTER
UNDERSTANDING OF THESE FACTORS.
NOW, CHRONIC DISEASES ARE YOU
KNOW VERY PREVALENT SO WE KNOW
THIS, MORE THAN 11 IS VERY
COMMON AND MOST ADULTS, 2/3RDS
OF THOSE OVER 65 HAVE 2 OR MOWR
CHRONIC CONDITIONS AND WE'RE NOT
JUST TALKING ABOUT OFTIOARTRITIS
AND HYPERTENSION, THE LIST OF
MORE CHON THINGS ARE WELL KNOWN
TO MOST OF THIS AUDIENCE, WE
ALSO KNOW THAT PEOPLE OVER 40
ABOUT 69% TAKE A PRESCRIPTION
DRUG AND AT THREEOF THE 22% USE
5 PRESCRIPTION DRUGS A DAY OR
SOMETIMES LESS THAN DAILY.
BUT RESEARCH WE DO CLINICALLY
ALMOST ALSO FOCUSES ON 1 DISEASE
AT A TIME AND WE DO HYPERTENSION
AND WE DO HYPERTENSION AND WE DO
CHRONIC LUNG DISEASE, WE DO
CHRONIC LUNG DISEASE, WE DON'T
THINK ABOUT ALL THE OTHER THINGS
THAT AFFECTING OUR INDIVIDUALS
AND OUR STUDIES AND THIS WE HAD
A FUNDING OPPORTUNITY FOR THIS
AND ESSENTIALLY GOT MOW
APPLICATIONS THAT WERE EITHER ON
TARGET OR FUNDABLE, WE HELD A
SCIENTIFIC WORKSHOP THIS YEAR TO
ADDRESS THIS, AND NOW ADD TO
THIS COMPLEXITY OF MORE THAN 1
DISEASE, THE WHOLE IDEA OF
PREVENTION, OH BY THE WAY, YOU
HAVE TO GET YOUR YOU NEED TO GET
SCREENED FOR COLON CANCER OR
LACK OF INTEGRATION AND
HEALTHCARE SERVICES AND IN MANY
WAYS NIH LIVES IN A DOUBLE.
WELL ARE EXAMPLES OF GOOD
INTEGRATED HELT SERVICES MOSTLY
OUT IN THE WESTERN PART OF THE
UNITED STATES, SOME IN THE
NORTHEAST, NOT IN WAWASHINGTON
DC AREA AND THIS AND THESE 2 ARE
MAINLIOR HEALTHCARE PROBLEMS IN
OUR HEALTHCARE SYSTEM, NOW LET
ME TURN TO THE ISSUE OF RACISM
OR DISCRIMINATION, AND THAT IS
PERVASIVE IN OUR SOCIETY AND
HEARD A LOT ABOUT SINCE 2020 AND
AND DATA FROM THE KAISER FAMILY
FOUNDATION SURVEY ON RACISM
DISCRIMINATION, THEY CHAISM THE
QUESTIONS OF COURSE AND RELEASE
THESE DATA, THE 1S I'M SHOWING
YOU HERE IN DIAGRAM OF 2023, BUT
THE QUESTION IS IN THE
HEALTHCARE VISITS ISSUES SO YOU
SEE THE AFRICAN AMERICANS, AND
THE RACIAL ETHNIC MINORITY
POPULATIONS THAT THEY COLLECTED
DAILY BASIS THEA ON WERE IN THE
10-12% RANGE AND 3% FOR WHITE
AMERICANS SO CLEARLY WE HAVE A
PROBLEM.
IN SOCIETY WHERE WE SHOULD BE
THE ANSWER, QUEE STILL HAVE A
PROBLEM, BUT IT DOESN'T EXIST IN
MY NEIGHBORHOOD IS THE WRONG
RESPONSE AND LOOKING FOR WAYS TO
FIRST OF ALL ACKNOWLEDGE IT AND
ADDRESS IT DIRECTLY IN WHATEVER
WAYS WE CAN, WE DON'T HAVE A
CURE FOR THIS, I THINK IS REALLY
IMPORTANT, NOW IN A RESEARCH
CONTEXT, WE THINK OF THIS, WELL,
WHAT'S THE RESEARCH CONSTRUCK
ABOUT RACISM AND ALMOST ALL THE
WORK WE KNOW ABOUT HAS BEEN DONE
IN THE INTERPERSONAL, LIKE THE
PRIOR QUESTION WE DID, SO THERE
ARE GOOD MEASURES, THERE'S GREAT
STUDIES THAT ASSOCIATE HAVING
HAD EXPERIENCED DISCRIMINATION
ASSOCIATED WITH CERTAIN HEALTH
OUTCOMES, IN A VARIETY OF
DIFFERENT CONTEXT, MOST CLEARLY
ON BEHAVIOR, SUBSIDIARY STANCE
USE, CONTROL, MENTAL HEALTH
SYMPTOMS IN ADOLESCENCE AND
ADULTS BUT IT ALSO HAPPENS WITH
CERTAIN CARDIOVASCULAR
REACTIVITY STUDIES AS WELL AS
METABOLIC CHANGES AND THEN
FURTHER DOWN YOU GO, THE HARDER
TO MAKE A CAUSAL INFERENCE
ALTHOUGH THERE ARE DATA SUPPORT
THAT, NOW IT APPEARS THAT IN
DISCRIMINATION WORK, I'VE BEEN
FOLLOWING, INCLUDING SOME FROM
OUR INTRAMURAL INVESTIGATORS
THAT LIFETIME EXPOSURE IS REALLY
WHAT IS MOST IMPORTANT AS
OPPOSED TO WHAT IS HAPPENING IN
THE LAST YEAR, OR WHAT HAPPENED
TO YOU LAST WEEK.
AND THIS MORE RECENT EVENTS ARE
LESS RELEVANT TO WHAT HAPPENS
AND I THINK IN THE--MET MODEL OF
ADVERSE EVENTS FOR CHILDREN,
THIS SORT OF CUMULATIVE CHRONIC
STRESS OF BEING EXPOSED TO
DISCRIMINATION OR ADVERSITY, IS
THE MODEL OF HOW THIS RESULS IN
HEALTH PROBLEMS 30-40, 50 YEARS
LATER.
INTERNALIZED RACISM IS ANOTHER
WAY SO HOW DO INDIVIDUALS
SUPPLEMENT THIS, THEY ACCEPT
INFERIORITY IN SOME WAYS PEOPLE
HAVE COINED THE TERM OR USED THE
MEASURE CALLED JOHN HENRYISM,
WORK, WORK, WORK, BECAUSE THAT'S
WHAT YOU ARE EXPECTED TO DO
UNTIL YOU DIE OR BIOLOGICAL
INFERIORITY AND THERE ARE WAYS
AT GETTING AT THE BIOLOGY OF
THIS THROUGH MEASURES SUCH AS
ALOE AT THAT TIMIC LOAD, PEOPLE
HAVE ALSO STUDIED THINGS LIKE
TELOMERE LENGTH IN THIS REGARS.
ADOLESCENCE I'VE BEEN ASKED
ABOUT PERCEIVED SOCIETAL
DISCRIMINATION, SO WHAT DO YOU
THINK IS GOING ON OUT THERE AND
THAT'S BEEN ASSOCIATED.
SECOND HAND EFFECTS OF RACISM
HAVE HARDLY BEEN STUDIED SO
WHAT'S IT LIKE FOR SOMEONE WHO
GROWS UP WITH A VICTIM OF RACISM
AND DISCRIMINATION WHO DOESN'T
NECESSARILY HAVE INSIGHT INTO
THAT AND THEN MOST RECENTLY WE
FOCUS ON STRUCTURAL INSTITUTION
AND DISCRIMINATION, RELATED TO
POLICIES WHERE THE RED LINES
MAPS OF THE 1930S AND 40S ARE
REALLY THE MOST INFAMOUS IN
TERMS OF HOW THE USES MANAGED
THAT AT THAT TIME AND LED TO
INIQUITIES, IN ACCUMULATION OF
EQUITY OF ECONOMIC EQUITY OF
HAVING ACETS FOR AFRICAN
AMERICANS AND TO SIMILAR EXTENT,
ALTHOUGH MAYBE LESS SEVERE FOR
LATINO AMERICANS IN THE U.S.
SO THIS, IS 1 STUDY FROM 1 OF
OUR TENURED TRACK INVESTIGATORS
LOOKING AT DISCRIMINATION
SOCIETIED WITH ALL CAUSE
MORTALITY WITH THE MULTIETHNIC
STUDY OF ABNORMAL GLUCOSE
TOLERANCELER O SCLEROSIS, AND
YOU CAN SEE IN THIS ANALYSIS
THAT EVERY DAY DISCRIMINATION
WAS NOT NECESSARILY SIGNIFICANT
ALTHOUGH IT TREPPEDDED TO THAT
WAY BUT THE LIFETIME
DISCRIMINATION WAS AND BOTH ALL
CAUSE MORTALITY AND IN LIFETIME.
THIS IS AN ANALYSIS OF CAUSE OF
DEATH THAT WE OFTEN IGNORE AGAIN
IN THE CLINICAL SETTING WHICH IS
FIREARM RELATED DEATHS AND DATA
FROM THE CDC AND 1 OF OUR
TENURED TRACK INVESTIGATORS JUST
LOOKED AT THE CDC WONDER
DATABASE AND SHOWED THAT FOR
BLACK CHILDREN AND ADOLESCENTS
THIS IS THE LEADING CAUSE OF
DEATH IN THE UNITED STATES,
FIREARMS AND IT'S IT'S REALLY
SOBERING TO SEE THIS AND WHERE
SHOULD OUR RESPONSIBILITY AS
HEALTHCARE SYSTEMS YOU KNOW OUT
THERE TAKING CARE OF POPULATIONS
OR CLINICAL SCIENTISTS BE IN
ADDRESSING ISSUES SUCH AS THIS,
IT'S TRICKY, I KNOW, IT'S NOT
STRAIGHT FORWARD, BUT IT IS A
CHALLENGE THAT WE NEED TO LOOK
FOR WAYS TO STEP UP, SO IN
WINDING DOWN JUST SOME GENERAL
THINGS, THE PATIENT CLINICIAN
COMMUNICATION LABORATORY IS A
POWERFUL TOOL THAT WE HAVE BOTH
UPDATER STUDIED AND
UNDERAPPRECIATED.
SO PEOPLE, INDIVIDUALS OUT
THERE, YOU KNOW LIKE TO LOOK AT
THEIR CLINICS, THEY MAY HAVE
LOST TRUST TO SOME EXTENT IN THE
HEALTHCARE SYSTEM CERTAINLY IN
SCIENCE, HAVE YOU THE COVID
PANDEMIC, ALL THESE THINGS THAT
HAVE BEEN HAPPENING, HOPEFULLY
WE CAN RECOVER THAT AND SOME OF
THAT BUT USUALLY PEOPLE STILL
TRUST THEIR DOCTOR, THEY STILL
TRUST THEIR HEALTHCARE, THEIR
CLINICIAN AS SOMEONE THEY COULD
RELY ON SO THAT'S THE POWER OF
THAT COMMUNICATION AND IT'S
BUILT ON THIS SUSTAINABLE
LONG-TERM RELATIONSHIPS AND WE
HAVE IM PERRIC DATA TO SAY THAT
PATIENTS ARE MORE SATISFIED WHEN
THEY HAVE BETTER COMMUNICATION
WITH L CLINICIAN, BETTER
ADHERENCE AND IN SOME CASES,
IMPROVED HEALTH OUTCOMES.
LISA COOPER WHO IS AT HOPKINS
DID ELEGANT QUALITATIVE STUDIES
20 YEARS AGO SHOWING THAT VISITS
IN CONCORDANT AFRICAN AMERICAN
PATIENTS AND DOCTORS WERE MORE
PATIENT CENTERED AND LONGER BY
2-3 MINUTES MUCH LANGUAGE
CONCORDANCE LEADS TO BETTER
LANGUAGE MEDICINE ADHERENCE FOR
LATINOS AND FROM A STUDY IN
KAISER AND A VALUE PLACED ON
COMMUNICATION SKILLS, IT'S
UNDERVALUED IN EVERYTHING WE DO
IN TERMS OF SELECTING STUDENTS
FOR MEDICAL SCHOOLS, SELECTING
RESIDENTS, AND IN SELECTING
CLINICIANS AND FACULTY AND I
THINK IT'S AN IMPORTANT AREA WE
NEED TO RECOVER AS MUCH AS
POSSIBLE.
NOW IN PROMOTING HEALTH EQUITY
IN HEALTHCARE, THERE ARE A
NUMBER OF MACROSTRATEGIES IF YOU
WISH THAT CAN BE IMPLEMENTED, SO
FIRST IS EXPANDING ACCESS, SO IN
THE U.S. TODAY WE HAD THE
AFFORDABLE CARE ACT EXPERIMENT,
AND IT HAS WORKED I IT HAS
BECOME, I DON'T WANT TO SAY
INSTITUTIONALIZED IS TOO STRONG
BUT ACCEPTED AND EACH APPROVED
BY THE MAIORITY OF THE
POPULATION, WE STILL HAVE ABOUT
10 STATES THAT HAVE NOT EXPANDED
MEDICAID, LATINOS OR HISPANICS
HAD THE MOST UNINHURRED GROUP IN
THE UNITED STATES, SO WE HAVE
GOOD SYSTEM TO COVER CHILDREN,
LESS THAN 2% OF CHILDREN ARE
UNINSURED AND IT SHOULD BE UNDER
1%, WE HAVE A GOOD SYSTEM,
MEDICARE TO TO COVER ADULTS OVER
65 BUT IT'S THAT 18-64 GROUP
THAT IS--THAT SUFFERS THE MOST
FROM HEALTH INSURANCE, THAT
SUFFERS FROM LACK OF HEALTH
INHURRANCE BECAUSE OF
EMPLOYMENT, THEY'RE MUCHED IN AN
OCCUPATION THAT DOES NOT PROVIDE
HEALTHCARE IS AS A POTENTIAL
BENEFIT AND THIS IS WHERE 20% OF
LATINOS ARE UNINSURED MAYBE
COMPARED TO 14-15% OF AFRICAN
AMERICANS AND UNDER 10% FOR
WHITES AND ASIAN AMERICANS.
THE OTHER IS PATIENT CENTERED
CARE, I ALREADY TALKED ABOUT
THIS, WE REALLY NEED TO
STRENGTHEN PRIMARY CARE IN OUR
COUNTRY.
WE USED TO EMPHASIZE IT AND
REWARD IT, NOW THE PRIMARY CARE
CLINICIAN, CAN'T DO EVERYTHING,
BUT A PRIMARY CARE CLINICIAN CAN
CERTAINLY BE THAT TRUSTED FIRST
POINT OF CONTACT FOR CHRONIC
DEC, FOR PREVENTION, FOR NEW
PROBLEMS AND FOR THEN CONNECTING
TO THE SPECIALTY NEIGHBORHOOD
AND THIS NOTION IS STRONG IN
SOME PARTS OF THE COUNTRY AND
ABSENT IN OTHER PARTS OF THE
COUNTRY.
IT IS BEING REPLACED IN PART BY
CONCIERGE MEDICINE WHERE YOU PAY
A FEE AND YOU GET ACCESS TO A
DOCTOR, TO A CLINICIAN, AND THE
CONCIERGE MEDICINE HASN'T BEEN
STUDIED BUT MY SENSE IS THAT IT
MOSTLY DRAWS ITS PATIENTS FROM
THE HEALTHY POPULATION AND ONCE
PEOPLE GET SICK, THEY GO
ELSEWHERE.
AND SO I THINK THIS IS A REALLY
IMPORTANT AREA THAT WE NEED
BETTER DIRECTION IN FROM POLICY
WISE, COORDINATION ASSISTANCE,
WE LEARNED A LOT ABOUT WHAT GOOD
PATIENT NAVIGATORS CAN BE IN
GUIDING PEOPLE THROUGH COMPLEX
SYSTEMS BOTH TO BE ON THE
TRANSPLANT LIST, TO MAKE SURE
THAT THEY END UP GETTING
REFERRED FOR DIALYSIS WHEN THEY
NEED IT OR WORK UP AN
ABNORMALITIES NORM AT KREENING
TEST ON ABNORMAL MAMMOGRAM,
SCREENING TEST, CHEST CT FOR
EXAMPLE, AND THEN TARGET
CONDITIONS PEOPLE WITH SEVERE
MENTAL DISORDERS WHO ARE IN THE
EMERGENCY ROOM 5 TIMES A MONTH
DURING WORKING HOURS AND YOU
KNOW WHY WASN'T A HEALTHCARE
SYSTEM WANT TO INVEST IN
MANAGING THAT DIFFERENTLY THAN
HAVING THEM SHOW UP IN THE
EMERGENCY ROOM?
SIM LOORLY FOR SEVERELY OBESE
PATIENTS WE GET A LITTLE BIT BET
THEY'RE WE GET MORE END OF LIFE
CARE, PALLIATIVE CARE IN PLACE
TO MANAGE THOSE PATIENTS, HOW WE
LEVERAGE IT AND HEALTH RECORD TO
IMPROVE EQUITY THERE'S A LOT OF
POTENTIAL, IT'S GOTTEN BETTER,
IN THE LAST 10 YEARS, YOU CSF, I
SPRBSED IT AS A CLINICIAN, AS
I'VE GOTTEN OLDER, I EXPERIENCED
IT AS A PATIENT, HOW MUCH BETTER
THE PORTALS ARE AND HOW MUCH
BETTER COMMUNICATION THERE CAN
BE THROUGH THE GOOD FUNCTIONING
SYSTEMS.
AND THEN HAVING PERFORM APSE
MEASUREMENTS.
SO HOSPITALS FOR A LONG TIME
BEING REWARDED FOR SHORTER
LENGTHS OF STAY, RIGHT?
SO THE WORST THING THAT WOULD
HAPPEN IN A HOSPITALIZED PATIENT
IS YOU ARE DECERTIFIED NOW TO A
CHRONIC CARE FACILITY PAYMENT
LEVEL AND THEN, YOU KNOW, THE
PATIENT HAS TO GO SOMEWHERE SO
THEY STAY THERE UNTIL THEY LAND
SOMEWHERE, SO WHAT IF WE CREATE
INCENTIVES FOR HOSPITALS TO ALSO
LOOK AT EQUITY, SO, IF THEIR
READMISSION RATE IS 15% FOR
CARDIOVASCULAR CONDITIONS, IN
GENERAL, BUT AUTO20% FOR AFRICAN
AMERICANS FOR EXAMPLE JUST TO
THROW A NUMBER OUT THERE, WHAT
CAN YOU DO HOSPITAL TO MAKE THIS
COMCLOSER TO 15 AND REWARD IT
SIPS WE LIVE IN THAT KIND OF
SYSTEM?
ALREADY TALKED ABOUT COMMUNITY
ENGAGEMENT.
I THINK THIS IS AN ESSENTIAL
COMPONENT IN BOTH RESEARCH AND
CLINICAL CARE, SO KNOW WHAT YOUR
COMMUNITY IS ABOUT.
ANECDOTE ABOUT HOW THE CANCER
CENTERS, ABOUT 15 YEARS AGO WERE
GIVEN THE MANDATE THAT WE NEED
TO KNOW WHAT THEIR CATCHMENT IS,
AND WADO YOU NEED TO KNOW ABOUT
THE CANCER CENTER AND WHAT DO
YOU NEED TO DO ABOUT THE CANCERS
IN YOUR CATCHMENT AREA, SO FOR
YOUR HEALTH SYSTEM THAT WOULD BE
KNOW YOUR POPULATION, WHERE ARE
YOUR PATIENTS ADMITTED FROM,
THERE'S ONLY 1 MAYO CLINIC,
RIGHT?
AND THEY GET PATIENTS REFERRED
FROM ALL OVER THE WORLD AND ALL
HOSPITALS GET SOME OF THAT
REFERRAL BUT MOST OF THEM DRAW
THEIR PATIENTS FROM THEIR
IMMEDIATE GEOGRAPHIC AREA AND I
THINK MOST ARE NOT THAT
FAMILIAR, THAT ENGAGED WITH
THOSE COMMUNITIES IN A WAY TO
IMPROVE THE COMMUNITIES HEALTH
AND RECOGNIZES THE IMPORTANCE OF
HEALTH AND NOT JUST HELT CARE
AND RESOURCES TO PROMOTE
HEALTHIER COMMUNITIES.
A WORD ABOUT SEAL, THE COMMUNITY
ENGAGEMENT ALLIANCE THAT WAS
STOOD UP DURING THE COVID
PANDEMIC BETWEEN NIMHD AND
NATIONAL HEART LUNG AND BLOOD
INSTITUTE.
WE PROUD OF THE ACCOMPLISHMENTS
TO DATE BUT THIS IS A LONG-TERM
EFFORT WITH 21 TEAMS ACROSS THE
COUNTRY, WE'RE SHIFTING FROM
COVID TO CHRONIC DISEASES SO YOU
WILL HEAR--WE PUT IT OUT AS TO
MY PEERS MY DIRECTORS, MY PEER
DIRECTORS LAST FALL AS A MODEL
AND SAY, YOU KNOW, THIS IS WHAT
WE'RE DOING, WE COULD DO OTHER
THINGS, WE CAN'T DO EVERYTHING,
BUT WE CAN DO OTHER THINGS
BESIDES WHAT WE DID WITH COVID.
FINALLY, JUST A WORD THIS
DIVERSITY OF THE WORKFORCE,
THERE'S GOOD IM PERICAL DATA
THAT IF YOU TRAIN MORE WELL TIN
O AND AFRICAN AMERICAN DOCTORS
THAT MORE MINORITY PATIENTS,
MORE INSURES AND/OR UNINSURED
PATIENTS AND MORE POOR PATIENTS
WOULD HAVE HEALTHCARE.
THIS IS A STUDY FROM THE MEDICAL
EXPENDITURE SURVEY, PANEL SURVEY
FROM 2010 INVESTIGATOR WE FUNDED
ALTHOUGH HE DID THE WORK BEFORE
WE GAVE HIM THE GRANT, RACIAL
AND IGHT NICK MINORITY DOCTORS
CARE FOR PATIENT WHO IS
SELF-IDENTIFY AS MINORITY YET WE
MAKE UP 53 PARIS OF PATIENTS,
AND THESE PHYSICIANS WERE LIKELY
TO CARE FOR PATIENTS WITH BOTH
MEDICAID AND NO HEALTH INSURANCE
AND THESE ARE DOUBLE AMC DATA,
SORRY FOR THE COMPLICATED SLIDE
BUT THE BOTTOM LINE IS MEDICAL
SCHOOL GRADUATES IN 21 AND 22,
LOOK AT AFRICAN AMERICANS, IT'S
SEIVET% OF THE PHYSICIANS ARE
GRADUATING PHYSICIANS ARE
AFRICAN AMERICAN AND 6% ARE
LATINO AND HISPANIC, ADD UP THE
FEW NATIVE PACIFIC HAWAIIAN
PACIFIC ISLANDERS AND YOU YOU WE
MAKE UP ABOUT 33% OF THE U.S.
POPULATION IN 2020.
I'M NOT ASKING FOR DEMOGRAPHIC
EQUIVALENCE OR EQUITY BECAUSE
THAT'S NOT GOING TO HAPPEN BUT
WE HAVE TO DO BETTER AND THERE
ARE MANY CHALLENGES TO GET
THROUGH.
SO I WILL END JUST A FEW
HIGHLIGHTS, YOU KNOW I MENTIONED
INTERSECTIONALITY, WE ALWAYS
TALK ABOUT MULTILEVEL
INTERVENTIONS AND IN THE
CLINICAL RESEARCH, SO INTERVENE
WITH PATIENTS, INTERVENE WITH
CLINICIAN ANDS SYSTEM, AND
DELIVERY SO THAT'S WHAT WE ARE
ASKING YOU TO THINK ABOUT.
IN THE CLINICAL SETTING, IT
LENDS ITSELF TO THAT,
IDENTIFYING MECH INFORMS ARE
IMPORTANT, WE TALKED ABOUT
COMMUNICATION AND THEN
IMPLEMENTING STRUCTURAL CHANGES,
SORT OF THE IDEA, MAKE THE
STAIRS EASILY AVAILABLE AND EASY
TO USE IF YOU'RE ABLE TO WALK UP
THE STAIRS AS OPPOSE TO GOING UP
1 FLOOR IN THE ELEVATE SO I WILL
END WITH THAT, THANK YOU VERY
MUCH FOR YOUR ATTENTION AND I'M
HAPPY TO TAKE QUESTIONS HERE OR
ONLINE.
[ APPLAUSE ]
>> HI.
>> TOM, YES.
>> SO WE GREW UP IN THE MILITARY
HEALTH SYSTEM AND WHILE I THINK
THE MILITARY HELG SYSTEM BEN
APPROXIMATE FISHIARYS HAVE BEEN
COMPARED AGAINST BENEFICIARIES
OF OTHER HEALTH SYSTEMS IN SOME
REGARDS IN EMERGING ITS OF
PRIMARY CARE, OVERALL HEALTH,
SORT OF MORE GLOBAL MEASURES OF
HEALTH,IME NOT SO SURE THAT'S
BEEN DONE AND THE REASON WHY I'M
INTERESTED IS BECAUSE SOME SORT
OF CULTURAL CONNECTIONS IN THE
MILITARY HEALTH SYSTEM PROVIDERS
HAVE LOTS AND LOTS OF WAYS TO
IDENTIFY THE SOCIAL DETERMINANTS
THAT THEY HAVE ACCESS TO
RESOURCES TO HELP THOSE WHO ARE
LESS ABLE TO PROVIDE FOR
THEMSELVES.
SO I'M INTERESTED IN YOUR
KNOWLEDGE REALLY ABOUT LOOKING
AT THE MILITARY HEALTH SYSTEM
AND UNDERSTANDING IT FROM THE
HEALTH DISPARITIES POINT OF
VIEW, THANKS.
>> SO YOU IDENTIFY GAP IN MY
KNOWLEDGE, I DON'T KNOW MUCH
ABOUT THE MILITARY SYSTEM.
THERE HAVE BEEN A NUMBER OF MANY
ACTUALLY STUDIES ON THE VA
POPULATION WHICH I GUESS YOU GD
SAY IT'S NOT REALLY AN EXTENSION
BUT IT SORT OF IT FOR WHO'S
ELIGIBLE FOR VETERAN'S BENEFITS
AND THERE'S CLEAR LESS GAP IN
THE HEALTH DISADVANTAGE BETWEEN
BLACK AND WHITES IN THE VA
SYSTEM.
IN FACT, THERE'S A STUDY THAT
PROBABLY DONE MORE THAN 20 YEARS
AGO THAT SHOWED THAT MORTALITY
FOR EXAMPLE, PNEUMONIA WAS LOWER
FOR AFRICAN AMERICANS LOOKING AT
THE VA HEALTHCARE, SORRY, SOME
OF THAT IS I THINK MORE UNIFORM
HEALTHCARE IS MORE LEVEL PLAYING
FIELD OF YOU'RE IN THE SYSTEM,
YOU'RE GETTING ATTENTION AND I
THINK THE VA HAS EVOLVED IN A
DIRECTION ALONG SOME OF THESE
LINES OF STRONG PRIMARY CARE,
MORE TEAM CARE, MORE LOOKING AT
THE ASSPEBTS OUTSIDE OF THE
HEALTHCARE SETTING AND ALSO,
THERE'S DIFFERENT POPULATIONS
THAT GO IN THE MILITARY,
FREQUENTLY THE AFRICAN AMERICAN
WHO IS VOLUNTEER FOR THE
MILITARY WERE HEALTHIER THAN THE
REST OF THE COMMUNITY AND FOR
WHITES IT MAY HAVE BEEN THE
OPPOSITE, SO YOU SAW THE
NARROWING OF THE GAP.
ONE OF MY POST DOCS IN THE LAB
HAS BEEN ANALYZING DATA ON THE
SURVEY OF INCARCERATED PERSONS,
AND WE SEE SIMILAR KIND OF
RESULTS, NOW THIS IS ONLY A
SURVEY, IT'S NOT HELT CARE, BUT
ON SELF-REPORT OF MENTAL HEALTH
AND PHYSICAL HEALTH ISSUES,
WHITES AND BLACKS ARE MUCH
CLOSER AND IN SOME THINGS BLACKS
ARE HEALTHIER IN THE PRISON
SYSTEM IN THAT CONTEXT, THIS IS
ABOUT 20,000 RESPONDENTS TO THIS
SURVEY, SO I THINK THAT THIS IS
AN AREA THAT COULD BE
POTENTIALLY USED TO LEVERAGE,
SAY, OH WE CAN DO IT IN THE
MILITARY, WHY CAN'T WE DO IT IN
OTHER CONTEXT AND NOT ENOUGH OF
THAT PROBABLY HAS BEEN DONE, SO
I AGREE.
THANKS.
YES?
>> SO I WANTED TO SAY THAIRK YOU
FOR YOUR TALK BEFORE I ASK MY
QUESTION.
>> THANK YOU.
NSO
N--
>> SO I HAD QUESTION ABOUT SOME
OF THE IMPLEMENTATIONS YOU WOULD
RECOMMEND FOR MORE RURAL
COMMUNITIES AND FOR LACK OF A
BETTER TERM HEALTHCARE AND
GROCERY DESERTS.
WOULD YOU--HOW WOULD YOU
RECOMMEND GOING ABOUT PREVENTING
CHRONIC ILLNESSES IN MANY OF
THESE LOW AND MIDDLE INCOME
COMMUNITIES.
WOULD YOU CARE MORE FOR
PREVENTION RATHER THAN OR WOULD
YOU CARE MORE FOR PREVENTION
WANT TO SHIFT MORE FOR
PREVENTION RATHER THAN TREATMENT
OR WOULD YOU JUST STILL WANT TO
GIVE MORE MEDICINE FOR EXAMPLE,
LIKE THAT JUST CAME UP WHEN YOU
WERE DISCUSSING HOW DOCTORS
WEREN'T--I MIGHT HAVE
MISUNDERSTOOD WAS THAT DOCTORS
WEREN'T PRESCRIBING STATIN TO
WOMEN OR?
YEAH?
>> CORRECT.
YOU ASKED ABOUT LOW INCOME AND
COMMUNITIES OR RURAL COMMUNITIES
OR BOTH?
>> BOTH JUST FOR PREVENTION
RATHER THAN--
>> RIGHT, RIGHT.
THE EASY ANSWER IS TO SAY YOU
NEED BOTH, PREVENTION YOU NEED
HEALTHCARE FOR SOME PREVEPTATIVE
MEASURES BUT YOU NEED TO THINK
ABOUT COMMUNITY CONTEXT FOR
OTHERS AND SO YOU DON'T NEED AS
MUCH A DOCTOR OR CLINICIAN TO DO
PREVENTION, YOU NEED STRUCTURAL
CHANGE IN HOW PEOPLE ARE ABLE TO
BOTH INCREASE PHYSICAL ACTIVITY,
AFFORD OR ACTUALLY HAVE ACCESS
TO HEALTHIER NUTRITION OR LESS
ACCESS TO NOT HEALTHY NUTRITION,
YOU KNOW, THE HIGHLY DENSE
CALORIC STUFF THAT IS NOT
EXPENSIVE THAT REALLY IS
PROBABLY MORE HARMFUL TO US THAN
WE EVEN ASSUME IN TERMS OF
CARDIAC DISEASE IN THE LONG-TERM
AND CAUSING METABOLIC
DYSFUNCTION AND CANCER.
SO I THINK YOU NEED BOTH
STRATEGIES.
AND THERE'S ALSO THIS SORT OF
EXTRA ISSUES ABOUT POLLUTION FOR
EXAMPLE AND WE KNOW THAT
PARTICULARLY, THE MATTER, THE
POLLUTION 2.5 IS GOING UP AND UP
AND UP, AND IT IS ASSOCIATED
WITH INCREASE RISK OF PEL
MONITORARY DISEASE, STROKE, AND
WE KNOW SOME THINGS THAT NEED TO
CHANGE IN ORDER TO MAKE THIS
BETTER, AND SO I THINK THESE ARE
ALL MACROFACTORS THAT WILL
MATTER TO MAKE THE POPULATION
HEALTHIER, BUT YOU ALSO NEED
HEALTHCARE.
I MEAN PEOPLE IN A HEALTHY
COMMUNITY MAY HAVE ACESES TO
THESE GOOD THINGS BUT MAYBE THE
FREEWAY GET TORN DOWN, IT WILL
NEVER HAPPEN, BUT YOU KNOW YOU
DON'T HAVE TRUCKS GOING BY,
DIESEL TRUCKS GOING BY WHERE YOU
LIVE ALL THE TIME BUT I STILL
CAN GET SICK.
YOU STILL CAN GET HYPERTENSION
OR YOU CAN STILL HAVE AN INJURY
AND YOU NEED A PLACE TO GO, SO
YOU NEED QUALITY HEALTHCARE AND
I THINK WITHIN HEALTHCARE, WE
OFTEN GET SORT OF--WE MEANING
THE HEALTHCARE PROVIDERS AND
SYSTEMS ENAMORED IN NEW THINGS,
NEW TECHNOLOGY, NEW THERAPIES,
SOMETIMES THE OLD STUFF ACTUALLY
WORKS QUITE WELL, WE JUST DIDN'T
GET IT TO PEOPLE, AND THERE'S NO
BIG PIEWSH --PIEWSH TO PROMOTE
THEM WHY THE THEY TILL GO ALONG,
YOU WILL SEE THEY MAY CHANGE THE
WAY WE PRACTICE A PARTICULAR
CONDITION, I THINK WE NEED TO BE
OPEN TO BOTH.
WE CAN'T ASSUME 1 OR THE OTHER.
>> ONE LAST QUESTION?
>> DON'T GO AWAY, I WILL CLOSE
THE SESSION.
I WANT TO SAY THANK YOU VERY
MUCH FOR YOUR COMPREHENSIVE
POWERFUL PRESENTATION, LIKE ANY
GREAT PRESENTATION, IT RAISES
MORE QUESTIONS THAN ANSWERS AND
SO, THANK YOU FOR YOUR
LEADERSHIP.
I THINK IN OUR COUNTRY, THERE'S
THIS RECONNING THAT'S
CONSIDERING OVER THE PAST FEW
YEARS THEY THINK HAS BEEN LONG
OVERDUE BOTH IN OUR COMMUNITIES
AND CLINICAL SETTINGS AND I WANT
TO THANK YOU FOR YOUR LEADERSHIP
WITH NIMHD.
>> THANK YOU SO MUCH TOM.
THANK YOU. 1770 01:02:58,608 [ APPLAUSE ]