Structural racism, structural violence and COVID-19: We must fight both epidemics

The novel coronavirus which causes COVID-19 does not discriminate. Despite the common human error of teleologically imputing motivation to organisms – or even inanimate objects – this virus, like other viruses, like other microorganisms, does not choose its victims by conscious intention. Like other microorganisms, it is opportunistic, attacking people who are available and do not mount an immune resistance against it. In the case of COVID-19, that was, at least initially, everyone who was exposed, so that while it began in China it was brought to other countries by international air travelers, generally among the more economically privileged.

But it didn’t stay that way. While the virus does not discriminate, human societies do, and poor people always suffer more. In many countries, including the US, the UK and Brazil it is minority populations, people of color, and especially Black people who have borne the brunt of the epidemic. This disparity is particularly dramatic in countries with long histories of racism that have vicious right wing leaders. The Guardian describes Enormous disparities': coronavirus death rates expose Brazil's deep racial inequalities. In the US, another country with these two characteristics, the disparities are so large that they should be shocking, except we are used to them now. This graph from the NY Times shows the disparity in COVID cases based on income, (the graphic shows NYC and Chicago, and clicking on the interactive link lets you look at the specific but similar patterns in many major cities), but the disparity based upon race is layered on top of that.

Study after study demonstrates this disparity.  They are revealed in hearings in the House of Representatives, and have been demonstrated for many chronic diseases. The cause is Structural Racism, which systemically has placed Black people in lower-paying jobs with much less hope for advancement and the accumulation of wealth, more blighted and polluted neighborhoods where access to basic services (food, transportation, recreation) is worse, segregation of schools either by law (de jure) or de facto in which education is worse, and more limited, and the incredible chronic stress of racist practices in society. This clearly manifests in the fantastically high rate of police brutality against Black and other people of color in the US, as has been demonstrated again and again, and with the murder of George Floyd has led to what (we hope) will be sustained and sustainable demands for change, and in the psychological stress that the ever-present danger of such acts along with less lethal racist treatment wreaks on the people experiencing it. All of us are worn and depleted by acute stress situations (“fight or flight”, with the exhausting secretion of adrenergic hormones) and need to rest to recover, but the chronic condition of stress experienced by oppressed and repressed people leaves no room for recovery, weakens resistance, increases chronic disease and shortens lives. Medical students (at least that large majority who are white) sometimes find this the “soft” stuff, not like the cellular level biochemistry and physiology, that sounds more “real”, but this is not so. There are studies that demonstrate, concretely, cellular level indicators of longevity (leukocyte telomere length) are shorted in people undergoing chronic stress, overall,[1] and in many specific conditions, including PTSD, chronic lung disease, Alzheimer’s disease, and chronic racism.

Our healthcare system is responding, but much of it not in a way that will help stem the epidemic. Recently, I wrote about ‘Rich hospitals get the bulk of government bailouts: It's the American way!’ (May 26, 2020), and more recently information comes to light that shows many systems are doing even less to help America confront the virus, laying off thousands of actual healthcare workers, and more to line the pockets of their C-suite executives! While these egregious and unforgiveable abuses are worst in for-profit hospital systems such as HCA, they are also occurring in many large and prosperous “non-profit” systems.

The NY Times comments on Anthony Fauci, the NIH’s top virologist:

He described the pandemic as “shining a very bright light on something we’ve known for a very long time” — the health disparities and the harder impact of many illnesses on people of color, particularly African-Americans.

The coronavirus has been a “double whammy” for black people, he said, first because they are more likely to be exposed to the disease by way of their employment in jobs that cannot be done remotely. Second, they are more vulnerable to severe illness from the coronavirus because they have higher rates of underlying conditions like diabetes, high blood pressure, obesity and chronic lung disease.

Philip Ozuah, the CEO of Montefiore Medical Center in the Bronx, very hard hit by the virus, writes of the deadly combination of racism and COVID-19 writes that “I fought two plagues and beat only one”,

America has changed its behavior in such profound and fundamental ways to mitigate the coronavirus, from self-quarantining and working from home to wearing masks and literally risking our lives to care for the sick. As our streets fill every night with protesters demanding a change that has been too long in coming, I dare to hope that we as a people can summon the same selfless courage and determination to change our behavior to address the endemic racism and brutality that plagues our country.

Then finally we may rid ourselves of that deadly virus as well.

For a clear, angry, and cogent description of the roots, causes, current manifestations of, and discussion of what we might do, a recent entire episode of John Oliver’s ‘Last Week Tonight’ is  a must-view.  He starts with the horrific and (finally) increasingly known statistics – such as that in Minneapolis, people of color are 7 times as likely to be arrested as whites, and the incredible fact that in the US 1 in 1000 Black men can expect to be killed by the police! Toward the end he quotes Kenneth Clark commenting on uprisings in the 1960s. Clark describes how after each previous crisis, from 1919 on, the powers-that-be say the same things and nothing really changed. The stark reality that this is still true 50 years later is unavoidable. Oliver insists that things must change, that we need to direct address and change the way that police to their jobs, and indeed redefine what the role of the police should be. He states that ‘It’s about a structure built on systemic racism that this country built intentionally and now needs to dismantle intentionally.’

Some have suggested that the risk of spreading the coronavirus from people gathering in mass demonstrations is high. These demonstrations have even been compared to the right-wing “anti-mask” demonstrations.  The risk of infection is likely heightened, but care can be taken; the important point is that whatever is necessary to finally confront and end racist violence in this country, particularly by the police, must happen and must happen now. Bassett, Buckee, and Krieger from the Harvard T.H. Chan School of Public Health take this on directly and strongly in a recent Op-Ed in the NY Daily News, ‘Racism is a deadly virus too: a public health defense of these mass protests’. They contrast the risk of COVID-19 infection by demonstrators consciously and purposely not wearing masks to the anti-racist demonstrators who are doing their best to wear masks and practice physical distancing.  They conclude that:

Protesters are in the streets demonstrating against police brutality and white supremacy not because they are indifferent to the risk of COVID-19. They are doing what they can to protect themselves and their communities precisely because the institutions that are supposed to protect and serve them have been killing black people in this country far longer than the coronavirus has.

The evidence is in and is clear. Indeed, it has been in and clear for many generations. Racism exists, not merely in the beliefs and attitudes of some or many people, but in the intrinsic structure of American society. It is structural racism and structural violence. It continues to kill and harm people at intolerable rates. In the midst of a terrible global pandemic caused by the SARS-CoV-2 virus, we finally and thoroughly must fight and erase the epidemic of structural racism in the US.

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[1] Olveira BS, et al., Systematic Review of the Association Between Chronic Social Stress and Telomere Length: A Life Course Perspective, Aging Res Rev. 2016 Mar;26:37-52. doi: 10.1016/j.arr.2015.12.006. Epub 2015 Dec 28.

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The social mission of medical education: Admit different students

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”,[1] June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (www.beyondflexner.org), which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.

Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.

I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”,[2] we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better -- more often those that are public, newer, and not in the Northeast -- but the fact is that none is doing all that well.

The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.

In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine.[3] We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates,[4] even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine:  Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000[5]. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.[6]

As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled, process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.

Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.[7]

Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.

And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.

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[1] Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286

[2] Mullan  F, Chen  C, Petterson  S, Kolsky  G, Spagnola  M.  The social mission of medical education: ranking the schools.  Ann Intern Med. 2010;152(12):804-811

[3]  Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.

[4] Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).

[5] Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712

[6] https://www.aamc.org/data/facts/

[7] Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.

Research on disparities/inequities, in practices and communities needs much greater funding

This is my first attempt at a blog in several weeks; indeed only one in the last month. I took (and time will tell if I passed) the Family Medicine recertification exam, so I am now able to raise my head above water.

Research is the way we gain new knowledge. It is how we discover if the things that we are doing are the right things to do, or if they are of little or no value, or perhaps even of harm. In the decades after World War II, when the country was optimistic and growing and seeking new frontiers, science was a major area for investment by our government. Things were getting better, returned GIs found a plethora of well-paying jobs, were able to buy houses and cars and plan to send their children to college. American industry did extremely well, if not solely because of great planning and management here, because there was no competition from the rest of the world which had been devastated by the war.

Things were not all good, especially on the political front; there was the cold war, and the associated fanatic fear of Communists epitomized by Senator McCarthy, and there was a legitimate fear of nuclear. But, on the economic front, things were going well for the US. The growth benefited many more people, and the gap between the income of the average worker was large but not unconscionable. Not like today, where as demonstrated by much research, and the title of this HuffPost article, “CEO Pay Grew 127 Times Faster Than Worker Pay Over Last 30 Years”, (“It’s good to be a CEO!”), or in this graphic from Prof. GW Domhoff of UC-SC.

The most dramatic expenditures on science were on space travel; after the Soviet Union launched Sputnik, the first artificial satellite, in 1957 and the space race was on. With the election of John Kennedy in 1960, space exploration moved front and center. All of us who were schoolchildren, in addition to hiding under our desks to protect us from nuclear weapons, were much more productively engaging in a new-found, broad-based physical fitness program encouraged by the President. While Harry Truman was unsuccessful in passing a national health insurance plan, thanks to both the reactionary opposition of the AMA, and the fact that labor unions chose to demonstrate their effectiveness by negotiating health coverage rather than seeking political change as the Labour Party successfully did in Britain, in other areas of science, health moved to the forefront.

The National Institute of Health (NIH) became the major government institution funding medical research and saw enormous growth in the ensuing decades, including a doubling of the budget from about $15B to about $30B in the decade surrounding the last millennium. This fueled the development of an enormous expansion of medical research in laboratories, primarily in universities and medical schools. In addition, corporate support, mainly from pharmaceutical research companies, further enhanced the growth of these laboratories. There were many successes, of which the most famous is the sequencing of the human genome, but our understanding of human biology and how it might contribute to human health and diseases has been remarkably enhanced. Some of this research has led to true medical breakthroughs, with the creation of new drugs and treatment modalities that have sometimes been of great help to large numbers of people with common diseases, and sometimes of enormous help to a few with uncommon ones.

However (and you knew that there was going to be a “however”), the focus on laboratory research and new discoveries at the molecular, protein and genetic levels left unfunded areas of research at least as critical, but not seen as “hard science”, and thus not generally funded by NIH and drug companies. This is a problem. Yes, there are “clinical” research studies, but these are mostly trials of drugs and interventions in populations. The number of studies based in communities, looking at health disparities, and trying to discover how most effectively to have a positive influence on the health of people, populations, rather than occasional individuals, remains small.

 

Certainly, it has grown. As demonstrated in the graph, after the NIH budget doubled, it leveled off, “stagnated” given inflation, until the one-time infusions of American Recovery and Reinvestment Act (ARRA) funds in 2009. Funding for health disparities research has increased, both from NIH and from other federal agencies such as the Centers for Disease Control (CDC) and the Agency for Healthcare Quality and Research (AHRQ), which has but a tiny fraction of the funding that NIH does. NIH created Clinical Translational Science Awards (CTSAs) which funded centers at many medical schools to look at moving research into the community, but much more from the basic science laboratory to first-in-humans trials (or even from one basic science laboratory to another). A major new initiative of the Affordable Care Act (ACA) is the creation of the Patient-Centered Outcomes Research Institute (PCORI), designed to evaluate not just new treatments but how they affect people. However, even the community-based research has focused largely on the recruitment of research subjects to studies designed by academic researchers, rather than on directly studying issues that would improve the health of the people in those communities.

Part of the problem is that it is difficult to get community members to think about what would be in the best interests of their health and that of their communities. They are, after all, not trained in such assessment. In addition, particularly in the communities that are the most vulnerable, that have to greatest health inequities, people are just focused on getting by, paying the rent, buying food, working multiple low-wage jobs. However, another part of the problem is that research at this level is seen as less important and significant, particularly by those who have always focused on new discoveries in the lab and who control most of the agencies such as NIH.

But it is not true. No matter how wonderful the discoveries in the lab, no matter how much they might lead to new understanding, new drugs, new treatments, these are only of value if people benefit from them. So this requires clinical research in the real world, with actual people. But beyond this, if they are to benefit not just a chosen few, the interventions have to be studied among diverse populations, including people facing economic, social, psychological and environmental challenges. In addition, the delivery of these treatments is sporadic. It is clearly demonstrated that administration of aspirin is of benefit to people who have had heart attacks. So it should be used. Why, then, are half the Americans who should be on aspirin not? I don’t know. It probably isn’t cost. It requires research to find out why and to change it. Saying (as is often done) that “new medical knowledge takes 10-20 years to penetrate into practice” is not adequate. Finding out how to get this effective treatment to the people who need it is as important as discovering the treatment. This is known as “fidelity” research.

Finally, effective research on improving people’s health needs to involve medical practices, where the people are being seen. There are many Practice-Based research networks (PBRNs) around the nation, but they are all challenged by how busy the providers are seeing patients; this is at least as true in practices such as Federally-Qualified Health Centers (FQHCs) that care for poorer populations. And yet, without involving them in research, how can we know what is effective in delivering the “best quality” care, and how can practices at the point of care be changed?

This is not to say that we should not fund basic biomedical research or early clinical trials. Nor is it to say that the current programs from NIH and PCORI and others to fund work in health disparities and inequities, and in population and community health are not good. But they are too little. People working in basic laboratory research, early clinical research, practice-based research, and community health should not be competing with each other. There should be more money for all of it, but especially a lot more for fidelity research, community-based participatory research, and practice based research.

Where will the money come from? From policies that are used in every other successful country, and every time the US has been successful, progressive tax policies that take some of our wealth out of the control of private corporations, who use it only to sock away more money, and into the public sector where it can be used to benefit us all.

Beyond Flexner: Taking the Social Mission of Medical Schools to the next level

In my blog entry for June 20, 2010, A New Way of Ranking Medical Schools: Social Mission, I discussed the article by Mullan, Chen and colleagues that had just been published in in the Annals of Internal Medicine, “The social mission of medical education: ranking the schools”. That seminal article provided concrete data on how medical schools ranked based on 3 criteria related to social mission: percent of underrepresented minority students in their classes, percent of graduates practicing in health professions shortage areas (HPSAs) and percent of their graduates actually practicing in primary care following their residency training. Unsurprisingly, the schools at the top of these rankings were a very group than those at the top than of more traditional rankings, such as US News and World Report, which are based on criteria like reputation, selectivity (what percent of applicants are rejected?) and research funding from the National Institutes of Health (NIH). Indeed, those schools that tend to rank at the top in the latter set of criteria were generally at the bottom of the list in social mission.

It didn’t make those traditional "powers" happy to be ranked at the bottom, and so they did the two things usually done by people and organizations who are found to be lacking by the data: they denied that it was true, that somehow the data was wrong, and they attacked the values of social mission, saying, in essence, that the characteristics being measured by the social mission rankings were not the important ones. The important criteria, of course, were those in which they -- the schools ranked low in social mission and high in traditional rankings – did well. Denying the truth of the study was hard, because the statistics used for measuring the 3 social mission criteria were not inaccurate. Mostly, then, their argument was “Oh, that data is old. We are better now!” But the reason the authors looked at graduates from 1999-2001 was that it allowed them to see several years after completing their primary residency training, not only whether graduates were really practicing in HPSAs, but whether they were really practicing in primary care. Medical schools like to count all students entering internal medicine residencies as “primary care”, when only a small percent do not enter subspecialty fellowships or practice as hospitalists and actually end up in primary care. And, in fact, in that 8 year interval, in the first decade of the 2000s, the numbers got worse.

So these critics mostly focused on the second defense, downgrading the importance of social mission. The measures they suggested (which they do well on) were: 1) getting a lot of money to do research (a little self-fulfilling, since the NIH panels that award research grants are largely staffed by people at the institutions that get research grants; in addition, this research is overwhelming done in the basic biomedical laboratory or early clinical trials, not in the community or the general population); 2) having a great reputation so that faculty who want to get big research grants want to come work there and students with high grades, mostly from the elite upper and upper middle class, want to attend, and 3) having a great reputation, so “peer” evaluators will say “yeah, you’re good!”

One can reasonably argue that the 3 criteria examined by Mullan and colleagues do not completely reflect the social impact of medical schools. Other criteria might include creation of community training experiences, community involvement and engagement in providing venues for training and in determining the type of research carried out by medical school investigators, the degree to which research and programs carried out by the medical school decrease health disparities, and the degree to which the health of communities and populations are increased by the activities of the medical school in practice, research, and education. However, these are not the criteria that the traditional “top” schools want to be evaluated on. The fact is that they are doing what they do, and what they do does not address diversity of the workforce, disparities in health, community involvement, or modern models of interprofessional education.

The next step in the Social Missions of Medical Education movement occurred in Tulsa, OK, May 16-18, 2012 at the “Beyond Flexner” conference. 100 years ago Abraham Flexner was commissioned by the Carnegie Foundation to look at medical education in the US. As a result of his report, more than half of US medical schools closed. Those that remained were largely the ones that had adopted a scientific basis for their medical education and were based in or tightly tied with research universities. For over a half-century, these schools grew with emphasis on the biomedical research enterprise and the training of highly skilled subspecialists, and little interest in any kind of social mission. The social movements of the 1960s and 1970s saw the first large number of new medical schools, and then quiescence until this decade, with a number of additional schools being created. Many of those in both the 1970s and 2000s groups manifested, at least initially, a social mission – that is, they had the goal of actually producing doctors and research that would improve the health of the population.

“Beyond Flexner” was co-sponsored by Mullan’s Medical Education Future Studies group from George Washington University and the new University of Oklahoma-Tulsa School of Community Medicine, led by Dr. Gerry Clancy, President of OU-Tulsa. Under Dr. Clancy, OU-Tulsa has transformed from a site for clinical training of a portion of the students from the OU School of Medicine in Oklahoma City to become the first 4-year school officially called “Community Medicine”. It was also one of the 6 schools that were part of the follow-up study of social mission, and whose leaders presented some of their innovations and successes at the conference. Three, including OU-Tulsa, Florida International University, and the AT Still College of Osteopathic Medicine in Arizona, are in the newest group, and have yet to graduate a class. Their contribution was largely in the creative and innovative methods that they are using to select and enroll and educate students, emphasizing diversity, community-based education, dispersion of educational settings, ambulatory (rather than hospital-based) training, emphasis on primary care and concern for the social determinants of health and health disparities. (A fourth new school, the University of Northern Ontario, in Canada, was also part of this group.)

The 3 other schools were part of the prior wave of new schools created in the 1970s and have had significant social impact, Morehouse University, the Southern Illinois School of Medicine, and the University of New Mexico School of Medicine. These are certainly not the only schools that have made a major commitment to social mission, and perhaps they are not in all respects the perfect exemplars, but they are certainly among the leaders in the field. They are part of an international movement of medical schools that were founded in the same period, to create physicians who would have the skills to care for people (primary care), have the knowledge to do research on community and population health, have the relationships to train and work with people in community settings, and have the intelligence to challenge traditional methods of classroom teaching by increasing clinical and interprofessional training experiences. Representatives from these and other schools described pipeline programs, interprofessional training, dispersion of training sites, innovative curricula, emphasis on primary care, and many other models and efforts.

The bottom line is that outcomes matter, and that judging a school by the impact that it has on the health of the population is the gold standard. Biomedical research contributes important knowledge that may, someday, impact human health, but this can be done in research institutes (see, for example, Karolinska, Rockefeller, Insitute Pasteur, Stowers) and certainly should not determine the core mission of schools focused on training doctors and other health professionals. The steering committee of “Beyond Flexner” is developing key principles that need metrics to assess outcomes; I would suggest the following:

·       Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?

·       Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?

·       Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?

·       Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

Maybe by the time of the next “Beyond Flexner” conference, every one of our medical education institutions will have bought into these principles and their implementation, and be able to be examples of how it can and should be done.

Unintended pregnancy and health disparities

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In "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, I discussed the work of Steven Woolf, MD, as it relates to health disparities. The major point of that piece is that the health and mortality differences between groups, particularly racial groups, in the United States accounts for an enormous number of excess deaths. If that gap were closed, and everyone in the US had the same age-adjusted death rate as whites, the number of lives saved would far exceed those saved by all medical care. Indeed, it would far exceed the number of lives saved even by public health interventions, at least as narrowly construed. Many of the social interventions that Woolf and colleagues indicate would be necessary to decrease disparities could be thought of as “public health” in a broader sense, because they would improve the public’s health, but in general eliminating poverty and raising educational levels are not part of the narrower public health construct.

In “Unintended pregnancy in the United States: incidence and disparities, 2006”, published on-line-before-print in Contraception, Lawrence B. Finer and Mia R. Zolna of the Guttmacher Institute report on the disparities in a particular group, women of reproductive age, in relation to unintended pregnancy. They combined data from several sources, “…on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth… a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US  Census Bureau,” to assess rates of unintended pregnancy and disparities between groups, and compared  this data to rates in 2001.

 They found that the percent of unintended pregnancies remained high, with a slight increase (from 48% to 49% of all pregnancies) from 2001 to 2006. The actual rate increased from 50 to 52 unintended pregnancies for every 1000 women aged 15-44. There was a significant decrease in the rate of unintended pregnancies in women 15-17 years old, but this group still had the highest rates (79%, down from 89%). While the fact that an increased percentage of pregnancies in such young women were intended is not necessarily a good thing, the overall pregnancy rate per 1000 decreased from 47 to 42 in this group. The rates of unintended pregnancy went down with age, but all other age groups had an increase in their rates from 2001-2006, the largest in women 18-24. To say this again: the rates of unintended pregnancy went up in each age group except 15-17, but that group still had the highest rate, with rates decreased in each older age group.

The most important finding was the disparity in the rate of unintended pregnancy by characteristics other than age: by race/ethnicity, by income, and by educational level. The unintended pregnancy rate for women with less than a HS diploma (80 per 1000) was more than 2.5 times that of college graduates (30); the rates for women who were HS grads and those with “some college” were in between. The rate for Black women (91) and Hispanic women (82) was also 2-3 times that of white non-Hispanic women (36). Income, perhaps, had the greatest disparity: the rate for women at <100% of poverty (132) was more than 5 times the rate for women >200% of poverty (24).

OK. This is a lot of data, and maybe it is hard to follow. But the main point is simple: these are staggering differences, and they are difference based upon the same social factors that Woolf and his colleagues address. The magnitude of these differences overwhelms all the other factors that affect this rate. The women whose resources make them least able to economically provide for unplanned children are most at risk of having them.

The percent of unintended pregnancies ending in abortion also decreased, from 47% to 43%, with the greatest decrease (from 47% to 41%) in women 20-24, but rather than being a positive, this decrease is much more likely to reflect the decreased availability of abortion services than a shift in attitudes toward abortion. That is, a larger number of children are being born as a result of unintended pregnancy to families that will have difficulty caring for them. In addition, these families are getting less and less aid from public sources because the same folks who are against abortion and the protection of the “unborn” are also against social services that will help the families of the born.

This study was also the basis for the excellernt column “Failing Forward” by Charles Blow in the NY Times on August 27, 2011.  He makes these points very strongly, commenting on the policies that restrict access to abortion while effectively punishing the children:

“This is what we’re saying: actions have consequences. If you didn’t want a child, you shouldn’t have had sex. You must be punished by becoming a parent even if you know that you are not willing or able to be one. This is insane.”

As in all of Blow’s columns, he includes a telling graphic, here showing the “States of Child Hunger”, the rate and raw number of children in food-insecure households. There are over 17 million hungry children in the US, or 23.2% of all children. The highest rate is in DC, the lowest in North Dakota. After DC (32.3%), perhaps surprisingly, is Oregon (29.2%). However, after that, unsurprisingly, come the usual suspects , many of the states most commonly associated with poor social supports and frequently conservative Republican leadership: Arizona, Arkansas, Texas, Georgia, Mississippi, Nevada, South Carolina, Florida. Most of the New England states are clustered near the bottom (good) end of the list.

The whole thing is not good. Too many poor and hungry children, too little education, too little opportunity for too many women and their families. Too many people and families caught in the multiple challenges of poverty, poor education, and racial/ethnic minority status, all of which are independently associated with health disparities, and which are synergistic in their effect when found together. This is not a society to be proud of. This is a society that needs great change, and it is the change perhaps we’d hoped for with the election of President Obama.

Frequently, the comic strips (not even the overtly “political cartoons”) capture it best. Here is a link to a “Non Sequitur”, by Wiley Miller. Check out September 4, 2001, with the adventures of super “hero” “CongressMan”. Laugh. And then cry.

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"Health in All" policies to eliminate health disparities are a real answer

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At the recent American Academy of Family Physicians (AAFP) sponsored National Conference of Family Medicine Residents and Students (NCFMRS) held in Kansas City (hey, it can be an advantage to live in the Capital of Family Medicine!), I had the pleasure of hearing Dr. Steven Woolf’s presentation “Health Disparities and the Role of the Family Physician”. I have previously cited (eg, Economics and Disease Prevention, February 13, 2009) the work of Dr. Woolf, a professor in the Department of Family Medicine at the Virginia Commonwealth University (VCU) College of Medicine. He is one of the most distinguished health services researchers in the country, and a clear and articulate speaker.

His presentation, appropriately for residents and students, began with a description of the role of the family physician in the care of both individual patients and the communities in which they practice. He noted the major health toll exacted by “personal health behaviors”, headed by tobacco (accounting for 400,000 deaths per year) and including diet/activity (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behaviors (30,000), motor vehicles (25,000), and illicit use of drugs (20,000, presumably not counting licit use of prescribed drugs). Note that, of these, only microbes are in the usual “traditional” area of medicine. His point was that to truly improve health the practitioner needs to go outside the hospital or office to the community, where these causes of ill health are located. “Health in All” policies include transportation, land use, built environment, taxes, housing, agriculture, environmental justice, etc. As an example he notes that 2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle. While Russell Shorto’s “Opinionator” piece in the NY Times July 31, 2011, “The Dutch way: bicycles and fresh bread” points out that one advantage of using bicycles as much as the Dutch do is that you can’t carry more than a day’s worth of groceries so that the bread can be fresh and preservative-free, this is not the way of things in the US; poor access to healthful food is a big contributor to poor health.

 

Woolf then went on to demonstrate the familiar (but maybe not to residents and students) data on the remarkable health disparities that exist in the US, particularly by race, socioeconomic status, and educational level (although also by geography, language, and other characteristics). For example, the attached table shows a 24-29% disparity between the age-adjusted mortality rates of white and black males over the period from 1991-2000. The other table shows that the health status of college graduates is much better than that of people with some college, which in turn is much better than HS graduates who have been health than those who have not graduated from HS. These disparities are truly remarkable and should be intolerable. Woolf notes that while most of our current research is focused on finding treatments that are effective, we would save far more lives if we were to focus, instead, on equity by eliminating the health disparities gap.

In a “thought experiment” that he published with colleagues in the American Journal of Public Health in 2007, “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”[1], Woolf demonstrates that even if we attribute all reduction in mortality over to medical advances (nowhere near true; most are due to the types of societal change generally characterized as “public health”, such as clean water, sanitation, and cleaner air), eliminating the disparities that exist on the basis of educational level would dwarf that change, as shown in this table. 

But our society spends virtually all of its research dollars on developing new treatments that then are available to only a portion of our population, and have relatively little effect even on those who receive it. Big PhARMA spends $32 Billion/yr. While the National Institutes of Health (NIH), which is part of the Department of Health and Human Services (HHS), spends $28 Billion/yr, primarily on developing new treatments, HHS’ Agency for Health Quality and Research (AHRQ), which looks at systems and utilization, receives only $300 million/yr.

Woolf and colleagues have also developed a great new tool for visually looking at the impact of disparities on health on a state and county level. Called the “County Health Calculator” (http://chc.humanneeds.vcu.edu), it allows you to pick a state or a county and compare its income level and educational level to that of the entire country (for states) or the entire state (for counties), or one state or county to another. It also presents the “best” and “worst” levels (for state or county), and allows (this is really neat!) you to use a “slider” to move the indicator to find out how changing the educational or income levels up or down would affect mortality. That is, you can see how many more lives would be saved – or lost – if your state (or county) had the income or educational levels of the average, best, or worst state (or county).

The results are truly amazing.  In Kansas, for example, the two suburban Kansas City area counties are almost polar opposites. Johnson County has the highest level of education, measured as % of adults with at least some college, at 78%, and income, measured as % of adults in households that have a “basic income” (defined as at least 2x the poverty level), 86%. Wyandotte County is near the bottom, with a “some college” education level of 39% and a “basic income” level of 56%. (Statewide levels in Kansas are 58% for education and 70% for income.) Using the slider, we discover that if Wyandotte County’s basic income level of 56% were raised to Johnson County’s 86%, 201 or 28% of deaths would be averted per year. If the “some college” education level were to go from the actual 39% to Johnson County’s 78%, it would result in a reduction of 272, or 38%, in the annual death rate!

No drug comes close to this. No treatment of any kind comes close to this. If a new drug were shown to reduce mortality from a disease by 5%, or even 1%, it would get incredible advertising – hundreds of millions of dollars – and huge publicity, in both the scientific and lay press. But the simple fact that so many more deaths could be prevented, so many lives could be improved, by addressing the social determinants of health, is scarcely covered, and hardly funded at all.

We are in thrall to, primarily, the pursuit of corporate profit, but also to a “scientific” perspective that sees new discoveries as the true goal of research rather than “moving the bar” and changing the actual outcomes for actual people. Eliminating health disparities, which improve health and decrease the death rate, will also “bend the cost curve” in ways that only improving access will not. In one of his slides, Woolf presents data from Milstein, et al, in a 2011 Health Affairs article [2] demonstrating that over the next 25 years neither providing coverage nor coverage + access to care, but only both plus “protection” – addressing behavioral and environmental risks – will do so.

There is no contest to the value of a dollar spent on changing social conditions as opposed to finding “more effective” treatments.  There is also no contest in where we actually spend our money. There is something rotten in the state, and it isn’t the state of Denmark.

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[1] Woolf S., et al., “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”, Am J Public Health. 2007;97:679–683

[2] Milstein B et al., “Why behavioral and environmental interventions are needed to improve health at lower cost”, Health Affairs 2011;30:823-832

Disparities in physician income are related to disparities in health

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A major focus of public health, about which I have written several times, is addressing the disparities in health arising from modifiable conditions (such as inequality of opportunity, income, and racial and ethnic differences). While it is common for those with privilege – wealth, health, opportunity – to believe that they have these privileges because they are “deserving”, i.e., because of their hard work, education, etc., such an outlook minimizes the critically important fact that there are lots of people who work just as hard and have very little. The “illegal immigrant”, working 3 minimum (or sub-minimum) wage jobs to try to just keep his or her family fed and housed, is not only not lazy, but working a lot harder than many of us who are able to enjoy weekends off, play golf, watch the kids’ sporting events.

So it is clearly not hard work alone. It is very much influenced by where you start, and what your opportunities have been. These are the social determinants of health (e.g., Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010) and the capability that people have of acting in healthful ways (Capability: understanding why people may not adopt healthful behaviors, September 24, 2010). It is common for people who have a lot to minimize, rather than to emphasize, the degree to which their position at the start of the race has affected their current position. Attacks on those who would seek to redress some of the most egregious inequities are still couched in terms of “economic class warfare” by those who have already won the war. Those with privilege are very concerned about change that would leave them with less of a leg up; they may give lip service to Horatio Alger heroes, but are more likely to wish to follow the model of George W. Bush. “If you’ve spent your entire life with the wind at your back,” a wise sage once noted (and I do not know to whom to attribute it), “a calm day seems unfair”. In terms of health, the connections are very clear. It is good for your health to be born rich. The Horatio Alger hero, pulled up by their own bootstraps, has worse health outcomes than the child born to privilege.

Health disparities, then, are real and important. But why should we – should anyone – be concerned about the disparities in physician income? After all, even the more “poorly” paid specialists, in primary care, make far more than the average American. Yes, they have worked hard to get into and through medical school and residency training, but, just as noted above, so have a lot of other people who will never make nearly as much. The problem is that, if the presence of a larger number/percent of primary care physicians is associated with improvements in the health of the population, and if the presence of wide disparities in income significantly influence students to choose higher paid specialties instead, then these disparities in health status are likely to continue and the overall health of the American people is likely to suffer. There is good data on both counts. Many of the posts in this blog have addressed the first, the positive influence of primary care on the health of the population (e.g., Lower Costs in Grand Junction: More Primary Care, Less High Tech, October 18, 2010; Primary Care, IMGs, and the Health of the People, August 14, 2010; and many others) and on health disparities[1]. I have also addressed the other point, the decrease in the number of students choosing primary care careers (e.g., Primary care specialty choice: student characteristics, July 12, 2010; Primary Care’s Image: A Problem?, November 17, 2009, and others).

A study published in the Archives of Internal Medicine by Leigh, et. al, “Physician wages across specialties”[2], is the most recent effort to quantify the differences. They utilized the large Community Tracking Study (CTS) of physicians from 2004-2005 to gather information on physician income. They grouped the physician responses into 4 broad categories (surgical, internal medicine and pediatric subspecialties [IMPSS], primary care, and other) and again into 41 specific specialties. They went beyond previous studies to calculate gross personal income on an hourly basis (thus controlling for hours worked per week) and did further adjustments to control for other variables, principally sex and age. They used a statistical manipulation to estimate incomes above the maximum set for the CTS (for some reason set at $400,000, much lower than many subspecialists make).

The outcomes were not surprising in comparison to previously reported data. In the 4 broad-group comparisons, primary care physicians averaged about $60/hr compared to IMPSS at $85, other medical at $88, and surgical at $92. In the single specialty comparisons, General Surgery was taken as a reference being actually near the middle ($86/hr), with the top incomes in neurosurgery ($132), radiation oncology ($126), and medical oncology ($114). At the bottom were family practice, general practice, general internal medicine, geriatric medicine, internal medicine/pediatrics, and “other” pediatric subspecialties (whichever those may have been) with a range of $50-$58.

There are several reasons to think that differences are, in fact, greater than those reported. There was only a 53% response rate to the CTS, and so we do not know if non-respondents made more, less or the same as respondents. “Hospital-based” specialties, specifically anesthesiology and radiology, which are among the highest-paid, were excluded. Other high-end specialties, such as cardiovascular surgery or transplant surgery, do not appear as specific specialties, and may have their incomes hidden when grouped with “thoracic surgery” or “other surgical specialties”. There are many sources of income for many physicians, including a variety of expenses that can be paid by practices and which would presumably be greater for higher income practices. Many highly-paid specialties are paid by hospitals directly (such as anesthesiology and radiology) or through “physician service agreements”. The correction used by the authors of the study for incomes over $400,000 could have been inadequate; certainly anecdotal experience in many locations would suggest that considering $400,000 as a reasonable top end for the highest paid physicians would understate that by at least half.
Nonetheless, the income differences, even in 2004-05, were impressive. Given the debt load that medical students (particularly those, obviously, from the less wealthy families) graduate with, the significant attraction to higher pay is clear.

The Wall St Journal, in two recent articles (“Secrets of the system”) published October 26, 2010, looked at the Relative Value Update Committee (RUC), a group of 29 physicians convened by the AMA from different specialty organizations that make recommendations to Medicare on how to pay physicians for their, well, relative value. One, “Physician panel prescribes the fees paid by Medicare” by Anna Wilde Matthews and Tom McGinty, describes how this group meets to divide up a pie that Medicare seeks to keep constant. In the other, “Dividing the Medicare pie pits doctor against doctor”, Matthews discusses the contentiousness that happened when primary care physicians (greatly outnumbered) challenged their surgical colleagues to get a higher portion of the money (that is, to revalue activities done by primary care physicians relative to surgical specialists).

In the same issue of Archives of Internal Medicine that Leigh’s article appeared in, Federman and colleagues[3] surveyed physicians about whether they thought reimbursements were inequitable or not; 78.4% agreed that they are, with not that much difference between generalists and subspecialists. However, when the idea of shifting payments from subspecialists to generalists was raised, there was a marked difference; 66.5% of generalists supported this, while only 16.6% of surgeons did; overall 41.6% were supportive and 46.4% were opposed. That is, for most specialists, paying generalists more is ok, but paying themselves less is not.

The WSJ‘s Matthews quotes an email from Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services (CMS) saying that the Medicare agency is moving to “improve Medicare's physician systems to correct historical biases against primary-care professionals." That needs to happen. The changes need to be dramatic. And they need to happen soon.

[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380
[2] Leigh JP, Tancredi D, Jerant A, Kravitz RL, “Physican wages across specialties: informing the physician reimbursement debate, Arch Int Med 25Oct2010; 170(19):1728-34.
[3] Federman AD, Woodward M, Keyhani S, “Physicians’ opinions about reforming reimbursement: results of a national survey”, Arch Int Med, 25Oct2010;170(19):1735-42.
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