In March, the Kaiser Family Foundation published an annual update to its Key Data on Health and Health Care by Race and Ethnicity. The analysis examines how people of color in the U.S. fare when compared to White people across a broad range of measures of health, health care and social determinants of health (SDOH).
The update reveals that Black, Hispanic, and American Indian and Alaskan Native (AIAN) adults fared significantly worse than White adults across most of the more than 30 measures examined. The new data are not surprising and reflect, in part, the devastation wrought on underserved communities by the COVID-19 pandemic. But, like this one, each report that highlights the persistent structural inequities that characterize the U.S. health care system carries shock value of its own.
American Academy of Family Physicians (AAFP) President Tochi Iroku-Malize, M.D., M.P.H., MBA, spoke recently with Medical Economics about the disheartening data and the findings that are of greatest concern to her as a family physician and as AAFP president. She also discussed how family physicians and other primary care clinicians can become grassroots change agents by addressing health inequity and SDOH in the examination room, one patient conversation at a time. The following transcript has been edited for length and clarity.
Q: The Kaiser Family Foundation study found that Black individuals, as well as members of other minority groups, fared worse than White individuals across most of the report’s 30 measures of health, which included life expectancy, overall health status, behavioral health and chronic disease, as well as across measures of SDOH, including full-time work, education, debt, food security, transportation and housing.
From your combined vantage point as a family physician, as president of that group’s professional society and as a physician with a background in public health, what findings are of the greatest concern to you and to the AAFP?
Iroku-Malize: I think that the report as a whole is of great concern, showing that Black, Hispanic and AIAN patients have worse health outcomes than White patients in most of the categories that you mentioned, including overall health and SDOH. Something that continues to cause grave concern is the mortality rate among both mothers and infants, particularly among minority patients. We know that Black infants were more than two times as likely to die as White infants, with 10.4 deaths per 1,000 births versus 4.4 deaths per 1,000 births. And the AIAN infants were nearly twice as likely to die as White infants with 7.7 deaths per 1,000 births. Black and AIAN women also had the highest rates of pregnancy-related mortality. We should be moving forward, not going backward.
Another finding that particularly stood out to me as a family physician is that adults of color were more likely than White adults to report not having a usual doctor or provider and to have to choose to go without care because of the cost. Approximately one-third of Hispanic adults, (a) quarter of AIAN adults and nearly 1 in 5 of Asian and Black adults reported not having a personal health care provider, compared (with) 16% of White adults. Children from minority populations were also less likely to have a usual source of care, although the disparities were smaller. It is crucial to establish a trusting relationship with a family physician for adults and for their children, so they have access to things like preventive care and chronic disease management to achieve better health outcomes.
Q: All the inequities and disparities that the report covers are well-documented, persistent issues in U.S. health care. But the COVID-19 pandemic really served as a floodlight across all these disparities. It seemed to further cripple an already fragile structure. Could you talk about how the pandemic has exacerbated so many existing inequities?
Iroku-Malize: There are three key issues here. The first is that the long-standing systemic health care and social inequities put many people from racial and ethnic minority groups at an increased risk of getting sick and dying from COVID-19. These inequities include discrimination in areas including health care, housing, education and finance. Secondly, the pandemic highlighted the impact of (SDOH) on patient access to health care. For example, if a patient doesn’t have reliable transportation, it’s harder for them to get to a vaccination site or to even get tested. Limited internet access could also make it harder to make appointments. Each of these challenges potentially put patients facing them at greater risk for severe disease, hospitalization or even death. And finally, the (AAFP), which I represent, recognizes the impact of racism within a health care system that has historically engaged in the systemic segregation and discrimination of patients based on race and ethnicity. Unfortunately, we still see some of the pandemic effects happening today. Hospitals and clinics that were once designated for racial and ethnic (minority population members) continue to experience significant financial constraints and are often under-resourced and understaffed. All of these factors cause inequities in access to and quality of health care, significantly contributing to racial and ethnic health disparities.
Q: Most of the systemic and structural change that needs to happen within health care delivery will need to come from the top down, from policymakers, lawmakers and institutional and governmental leaders. But those wheels turn very slowly. How can front-line physicians, as the primary contact with patients across racial, ethnic and socioeconomic strata, serve as grassroots agents of change? What can they do in the exam room that can help make a difference?
Iroku-Malize: There are a number of things. First, family physicians are already on the front lines. Because our goal is to achieve health equity for everyone, we don’t just screen — we intervene. When you’re with a patient, make sure that you’re screening to learn what (SDOH) may be affecting them. Stay informed and educated on these topics as well as on the resources available in your community to address them so that you can intervene. We can help mitigate health inequity by collaborating with local and regional entities including government, businesses, education systems (and) health care and social service providers. I say to people, yes, of course advocacy is important; and sometimes that will mean being in Washington, D.C. But you can advocate at your local level. In addition to your state capital, how about at the school board, when they’re discussing resources for schools in terms of food, like breakfast and lunches for the children who are having food insecurities? Also places of worship — you can volunteer at your place of worship, to provide health events where you give community members patient information flyers; you can have a health fair and give a talk there. I know in our area (metropolitan New York), we join with community-based organizations all the time, whether it’s places of worship or social groups, and we’re sharing information on a regular basis. We had an initiative (recently) focused on education on nutrition and how to address this in a food desert. Food pantries may get canned goods. What do you do with a canned good that has a lot of salt or sugar? How do we address that issue? If that’s what’s available to our patients, how can we make it healthier for them?
As part of the AAFP EveryONE Project that offers health care professionals screening tools to help identify patients’ social needs, we offer the Neighborhood Navigator. It is a point-of-care tool that lets clinicians connect patients with supportive resources within their ZIP code areas. A patient leaves our office with actionable items that may help address a particular (SDOH). And as patient health improves, community health does as well.
Q: Would you leave family physicians and other primary care physicians with three thoughts on how to build their own awareness and knowledge about and appreciation for the impact of SDOH on their patients?
Iroku-Malize: First, I recommend that clinicians take advantage of the (AAFP) Center for Diversity and Health Equity. This includes the EveryONE project I mentioned and the Neighborhood Navigator point-of-care tool. It offers tools and resources developed and collected specifically to help physicians address (SDOH) among their patients, advocate for health equity, promote workforce diversity and collaborate with other disciplines and organizations to reduce harmful health disparities.
Second, review the several AAFP (continuing medical education) courses that address how to develop strategies for navigating (SDOH) in clinical practice and how to participate in coordinated community care, among many other topics.
And third, most importantly, start a conversation with your patients. This can be guided by the (SDOH) screening tool I just mentioned or be a more casual conversation. Talk about what factors may be impacting their health and ability to access health care with a focus on how you can help them to take steps to address these challenges.