Social Disparities & Mending Mortality Rates

Dr. Chapa:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Hector Chapa, and joining me to discuss social determinants of health is Dr. David McIntosh. Dr. MacIntosh is Vice-President and Chief Inclusion and Diversity Officer at Wake Forest Baptist Medical Center, in Winston-Salem, North Carolina. Dr. McIntosh, thank you for being to the program.

Dr. McIntosh:
Thank you, Dr. Chapa for the invitation. I’m really excited to be here.

Dr. Chapa:
Now Dr. McIntosh, I wanna call your attention to something that’s been in the news as recent as December the 3^rd, 2020, where the Surgeon General called attention to something very dear to my heart, which is maternal mortality. I’m an OB/GYN, and this is something we can’t ignore. And in the call to action from the U.S. Surgeon General, it’s very clear in there, African American women have much higher rates of maternal morbidity and mortality, despite their education levels. And it’s something we cannot ignore, and social determinants of health was pulled out specifically from his call to action about the U.S. morbidity and mortality in pregnancy. Any thoughts or insights on that, specifically related to women’s care?

Dr. McIntosh:
Absolutely, and this reminds me of that New England Journal of Medicine article circa 1990. It’s the David Williams one, where he described how education is a mitigator of low birthweight babies. And they did an investigation, because what they found was, white women have much lower instance of low birthweight babies when they have more education. But it turns out that black women, when they have higher levels of education, it’s staggered. So a black woman with a graduate degree has the same low birthweight baby instance as a white woman with a high school education. And so, what they did was they investigated black women in Africa to understand if this was a genetic factor, recognizing that if it was a genetic factor, certainly they would see evidence of it in African women…

Dr. Chapa:
Sure.

Dr. McIntosh:
…versus African American women. And what they found was black women born in Africa actually have the same low birthweight baby instance as white women with college degrees in the United States. So what that meant was there’s something about being black in America that predispositions people for low birthweight babies. And they suggested that it’s about the environment that people are forced to undergo, being a black African American woman in American society. Now the interesting thing is that a black woman born in Africa, who migrates to the United States still keeps their same low birthweight baby instance as an African-born woman, but if she has a daughter, her daughter will have the same low birthweight baby as an African American woman. And so, her low birthweight baby incidence goes through the roof.

Dr. Chapa:
So I think we have to say that again, because that’s an important point here. Genetics is the foundation, but that doesn’t determine your overall outcome, because look how much genetics – which we say we can’t fix, to an extent – is modified by social environment. So that proves social environment can have both a beneficial and a deleterious effect on overall outcome. Is that correct?

Dr. McIntosh:
Yes. Absolutely. That study really helped people to understand that, wow the environment that we’ve created here has an impact. And so, let me also point to another data source to help kind of explain how some of these things work. There is a website called justicemap.org. If you go to this website, you can type in your city, you can type in your zip code, and you can zoom in, and you can see the racial demographics of your neighborhood, and you can zoom out and see the racial demographics of many neighborhoods around you. What’s really, really interesting about this website, is that you can not only see the racial demographics, but at the click of a button, you can also see the socioeconomic breakdown of those same community.

Dr. Chapa:
And those are accurate – to a point.

Dr. McIntosh:
It’s pulled from the 2010 census, so as soon as the 2020 census comes out, I hope and believe that they’ll update that website, so it is a little bit dated, but it’s still pretty accurate. It’s as accurate as almost any source you’re gonna be able to find with that kind of level of detail. When you click over to income, you will see that there is a remarkable overlap in communities that are highly affluent and the concentration of white folks in those communities. And where you see large communities of color, those are oftentimes low socioeconomic status communities. And it’s not to say that when you are a person of color that you are predestined to be low socioeconomic status. It is not to say that if you are white, there are not white people struggling. That is not the point at all.

Dr. Chapa:
Good.

Dr. McIntosh:
Those do happen. Those are real. But what it does suggest is that you cannot disaggregate race and socioeconomic status to say that socioeconomic status is a bigger predictor of somebody’s ability to be successful and healthy in life. What I would suggest is that socioeconomic status is inextricably intertwined with race, because of the way that our education system works, and the way that our employment system works, and the way that all of these systems work creates a barrier to success. And so, when we think about social determinants of health, here’s a perfect example of how this is in real time happening in our neighborhoods and the places that we live. And so, I think that we have to take a broad scope and a broad perspective on these issues, and so it’s not just race. It’s not just socioeconomic status. But really, those systems intersect and interact, so the transportation system does intersect there. The ability to have healthy food does intersect there. The city that I live in right now, Winston-Salem, North Carolina, there is a part of our town where there is a high concentration of folks of color. There is also a very low concentration of grocery stores in that community, which tells us a lot. The transportation system works in a way where it can be difficult to get to a healthcare provider. And it’s not by design, you know, there was not a person who said, “Put all the people there, and make it very difficult for them.”  That didn’t happen, but this is the hand we’ve been dealt, and so we have to be very, very, cognizant of how can we help and be restorative and really create an environment where people can be healthy. The town I used to live in, Louisville, Kentucky, there’s a street – they call it the Ninth Street Divide – and when you go past west of Ninth Street, there are predominantly communities of color. And so, when you go west of Ninth Street, not only is there very limited access to high-quality food, not only are there a prevalence of liquor stores, and things like that, but also in the community where all of the environmental justice problems are. So there are all sorts of industrial operations in existence in west Louisville. The difference in life expectancy between west Louisville and east Louisville is ten years – in the same town! That is especially salient, and it’s because of these myriad intersecting factors and determinants.

Dr. Chapa:
What I’ve learned from this, honestly, is we need to stop blaming patients. You know, blaming them for not taking medicine because they don’t wanna get better. It may be they don’t have resources or ability. It all comes down to awareness and an empathy for who we’re taking care of. So, as we start to wrap this up, Dr. McIntosh, I’m gonna leave the floor open to you. If you were going into medicine, into nursing, into health care, and somebody asked you, “What’s one of the most important things to learn?”  Yes, there’s pathophysiology, yes, there’s new drug therapies – but just about patient care, and overall outcomes related to this, what would you say to them?

Dr. McIntosh:
I would say that we need to know a great deal about the medicine, and the interactions with the body, and all of the things that you just spoke about. But there is a deep and dire concentration needed in some of the social sciences, so that we can begin to understand how intersecting social identities impact somebody’s ability to be healthy, and what it is we can do to take action. It is not good enough for us to only educate around these issues, it’s incumbent upon us, once we have more information, to do something with it. Maya Angelou once said, “Do the best that you can until you know better, and then when you know better, do better.”  I love that quote, because it suggests that we’re all already doing our best, but that we all have room to grow, and we together can make this better. The work that I do is sometimes very, very taxing, and it’s very, very tiring, and it sometimes leaves people, myself included, in a place of despair and hopelessness. But the thing that gives me more hope than anything is when I interact with the students coming into medicine. They come in with a real understanding of ideas around sociology and anthropology, and some of these disciplines where they’ve already had their hands dirty in it. And they come in asking really good and smart and hard questions about how do we impact somebody’s ability be healthy, and how do impact a population’s ability to be healthy. That inspires me, because that helps me to know that we are building the work force that will be equipped to do this work. And so, when I think about the most important lesson, it would not only be about the understanding of ourself and our role in this, but it would be the courage and the empathy to do something with it. When we’re doing that, we will be putting patients’ concerns and needs front and center, and we will impact somebody’s ability to be healthy, regardless of their social situation. And those social determinants are not gonna go away overnight, by the way. I mean, there is big wheels that have to turn. But in the environment we’re in, where the students who are coming in are demanding this content, and demanding this sort of interaction, it makes me very, very optimistic.

Dr. Chapa:
It’s getting better. I remember medicine was by default – regardless of discipline – very paternalistic. You came up with, “I told you what to do. I told you when to do X, Y, or Z.”  It was the father role in that authoritarian scheme. We now know that medicine is moving towards that patient-physician partnership, and part of that is dual understanding. And it’s true, I’ve had to rewire my brain, because I’ve always been in practice, but as an academician, where again, things are very black and white, and they’re not. Understanding these issues is definitely more important than ever. So Dr. David McIntosh, you’ve been fantastic. What insights you bring! And so, thank you for your opinions and your perspectives on this very important topic. It was great having you on the program.

Dr. McIntosh:
Thank you so much.

Dr. Chapa:
I’m Dr. Hector Chapa, and to access this, and other episodes in our series, just visit reachmd.com/cliniciansroundtable, where you can Be Part of the Knowledge. Thanks for listening.