Naomi Thyden’s Award-Winning Essay

Our ninth, and final, winning essay comes from Naomi Thyden of the University of Minnesota School of Public Health:

In a certain mood, it is fun to imagine the pieces that could fall into place to achieve health equity – policies that prioritize people over profits, and true power in the hands of people who have been marginalized. Then I think of women of color I know who have spent their careers dedicated to health equity only to be treated like less than the experts they are, and wonder if that is my future. To make progress toward health equity we must question the ways things have always been done and remember that if nothing changes, nothing changes.

Public education is one example of where we can rethink policies and values. Huge variations in spending on education help create disparities in childhood that last a lifetime. We are so used to this system that when it is time to raise a family, people unabashedly move away from diverse neighborhoods to places with ‘good schools’ without a second thought for the thousands of children who have no choice but to attend a ‘bad school’. Every child is entitled to a high-quality education in a school that treats them with respect, and we are far from that ideal.

We also need decision-making power in the hands of people who understand health disparities. A lifetime of witnessing and experiencing the conditions that create inequities is a qualification and we should treat it as such. When I worked at a public health organization ostensibly dedicated to health equity, I exhausted myself trying to change minds and explain causes of health disparities and still made little progress. Eventually, I turned my energy toward embracing the (limited) power I had, and directed funds to community-based organizations doing health equity work, hired highly qualified applicants of color who had been passed over, and disseminated needed health disparities data. Imagine the strides we could make if people with intimate knowledge of health disparities were unburdened from explaining every step they take.

A challenge for creating health equity is that so many sectors and disciplines are involved. However, it is also an opportunity because every person who is dedicated to the cause, wherever they work and whatever their role, has the power to propel us forward. It is uncomfortable to challenge the beliefs that our policies are based on, but the alternative is continuing to live in a nation where babies die because  of the color of their skin or the neighborhood they were born in. We will not solve health disparities in the next decade, but I am inspired by older generations who dragged us forward at great personal cost, and showed us that whether or not we are appreciated, there is work to be done.

 

Sara Paracha’s Award-Winning Essay

Our eighth winning essay comes from Sara Paracha of the Brown School at Washington University in St. Louis:

The definition of a health disparity as defined by Healthy People 2020 encompasses many subgroups of marginalized communities. While all communities have the commonality of a health difference, the cause for each may vary dependent upon geographical location or individual background. The first step in the process of eradicating health disparities over the next decade is identifying the root causes of the disparity. Causes for the disparity may include but are not limited to cost, access, discrimination, transportation, preexisting conditions, lack of education, stigma or culture. There is plenty of existing research that has been conducted that recognizes that a disparity exists, this research can be synthesized to find the gap and conduct further assessments or research as necessary. The next step is to implement programs and resources to tackle the causes. The resources include building safe neighborhoods and communities, increasing access to nutritious foods in food deserts and increasing mental health resources for youth and adults. Efforts need to decrease violence to develop less stressful environments for families. The education gap must be addressed because every child deserves a quality education regardless of their zip code. Special attention should be given to prenatal health and education on family planning to start the next generations health well. The bottom line in all of this is allocating funds to communities that need it most.

For practitioners, it is important to understand that these issues exist and why. Conversations on race, ethnicity, sexual orientation and gender are crucial and should not be taboo. Social workers, public health professionals, mental health professionals, physicians, politicians, researchers and others in contact with people in regard to any aspect of their health need continuous education on how to appropriately address concerns amongst populations that are different than their own. Some communities may not trust professionals who are implementing interventions in their communities, it is important these interventions are culturally appropriate and introduced as such. Learn about different cultures, their food, customs, religious practices, genetic histories and other factors that contribute to their overall well-being. Understand what the community feels they need most, ideas from the outside looking in are not always right. It is also important to understand where different communities obtain their health information, there may be a lot of misinformation guiding what some may believe are healthy practices. When the providers of services are more aware of the issues, they can then voice concerns to legislation that is related to any of these issues mentioned and be the voice for those who may not have the privilege of having one. The cost of health insurance, reproductive health care rights and funding for after school programs all impact the health disparity. Taking the steps listed above will guide the goal of eradicating health disparities, regardless of identities, and reach health equity overall.

 

Dorothy Hughes’ Award-Winning Essay

Our seventh winning essay comes from Dorothy Hughes of the University of Kansas School of Medicine:

Eradicating Health Disparities by Getting Creative with Workforce Solutions and Inter-Disciplinary Education

To eradicate health disparities, starting with the rural/urban divide makes sense. For those who suffer health disparities due to other reasons, being in a rural area layers on an additional barrier to accessing health care. If we can address this geographic barrier, we have a greater chance at successfully eliminating other barriers as well.

Immediately, we need to think creatively about how to distribute health care professionals, for example, the creation of job-sharing arrangements. Now and into the future, inter-disciplinary health professional education programs need to be encouraged and grown exponentially. Inter-disciplinary education must be the orientation of all health professional training programs because only through innovation and collaboration can we hope to eradicate health disparities.

In rural areas, physicians are scarce, and burnout runs rampant. Recently, I interviewed a surgeon who covers three rural towns. He has a quasi-partner, a surgeon who comes to town from a larger city once a week and acts as a release valve, doing elective cases and taking the pressure off the primary surgeon. In a frontier setting I visited, a surgeon was hired to work three days a week. She lived more than four hours away, commuting to her hospital in the middle of the week and lodging in a local bed and breakfast two nights per week. This allowed the hospital to gain surgical revenue, allowed the surgeon to manage her workload and call schedule, and most importantly, allowed this small town to retain access to surgical services.

In Kansas, some of our most admired medical communities are in rural areas where administrator and physician collaborations have built relationships with specialists around the region. The specialists travel to the rural areas a few times a month to see patients. These collaborations have also established telemedicine links with the state’s academic medical center, connecting patients to quaternary-level expertise. By thinking creatively about scheduling and staffing, they have managed to increase access to care for rural residents, thereby working to eliminate rural/urban health disparities, while also providing a unique practice experience for clinicians. These job-sharing and part-time arrangements are only the beginning. We should continue to pursue outside-the-box solutions.

It sounds simplistic, but putting future administrators and future clinicians in the same room during their education is crucial. In a joint DO/MBA program where I serve as adjunct faculty, the interactions are incredible between medical students – who come to class directly from clinical rotations – and the students who come from jobs as health IT consultants, rehab administrators, marketing directors, and more. Students bring their professional knowledge and personal perspectives, expanding the diversity of backgrounds in the classroom. This exposure to diverse perspectives pushes students to think about disparities and how they can be part of the solution, not by themselves, but as a team of future health professionals.

If eradication of health disparities is going to happen, it will be through innovative workforce solutions and inter-disciplinary education.

 

Nouran Ghanem’s Award-Winning Essay

Our sixth winning entry comes from Nouran Ghanem of the College of Health and Human Services at George Mason University:

An empathetic shift in consciousness is required. As a graduate student in health policy, I’m inclined to explain why informing policy to address health disparities is the best path forward. Policy enables change. Influencing governmental action guarantees a chance to promote funding for health disparity activities and evidence-based strategies in community and public health efforts. Albeit, a flawed and difficult path, it represents the pragmatic approach to affecting health disparities. Though, a tempting argument to make, one much simpler has overcame me recently.

Before policy, there is politics, and before politics, there are ideas, conversations, mass media, a knowledge economy, the tools of the information age; the widespread access of research and information. The impetus for a political thought is just that at an onset-a thought. In every historical example we have of change happening in the face of something we came to consider inhumane, wrong, immorally corrupt, egregious-people reasoned against opposition. The leaders of such historical movements for what culminates into our collective moral human progress argued why a particular social injustice was wrong in some way. They persuaded the public to empathize with a wrong situation, to regard it as indefensible and they succeeded. Reason is the “better angel of our nature”, deserving the greatest credit for the moral progress we enjoy today. I argue that this feeling of discontentment, cultivating it, making known the “wrong” situations which characterize health disparities is necessary for progress within the next decade in the amelioration of disparity.

If people, representatives, policymakers, pertinent industries began to increasingly see and comprehend the nature of health disparities then perhaps, society will begin to regard health disparity as an inconsistency in sound social justice, a glaring blemish for the “greatest nation”, continually harder to ignore. The idea though, must be present. It’s important that narratives, images of the challenging health situations prejudiced by disparity become visible all around, inducing empathy, disappointment and the impetus for change. A universal shift in consciousness towards caring about each other’s health or lack thereof, moving beyond self-centric mentality-the thinking that “if I have health insurance, that is all that matters” is required. I hope health disparities will become perceived as a social injustice just as we carry our most common, abhorrent examples of “wrong” from different times and/or circumstances.

Over time, I believe the shift in awareness will catch up to what we know and what we will know over the next decade about the social determinants of health, issues promulgated by access, cost and quality of care in the context of health disparities and recommendations designed by academia, industry and government. At this juncture, when people (and influential people) reach increased appreciation of health disparities and see themselves empowered by a substantial knowledge base, I believe a better policy environment for progressive action against health disparity is more possible than ever. Although not the focus of this case, I have confidence that policy, a preeminent instrument of change, can be used to create a more egalitarian and healthy union.

 

Anna Mullany’s Award-Winning Essay

Our fifth winning essay comes from Anna Mullany of the School of Public Health at the University of Massachusetts, Amherst:

The Political Economy of Health Disparities

The Declaration of Alma Ata, the culminating statement at the 1978 International Conference on Primary Health Care, began with this assertion:

“The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”

This affirmation of health as a fundamental human right explicitly recognizes that the underlying social and political determinants of illness must be concurrently addressed in order to eradicate the causes that give rise to preventable illness amongst the most vulnerable. Today in the United States, as the gap between rich and poor widens and with forthcoming cuts to healthcare, there is no better time to reflect on the Declaration of Alma Ata. In centering the principle of healthcare as a human right, this enables us to reenvision healthcare and also tirelessly work toward creative new ways to radically shift the political-economic system that determines these inequities.

The glaring pattern defining health disparities is that the poor disportionately suffer from ill health and preventable disease. From HIV-infection, to diabetes, to drug addiction and tuberculosis, the poor suffer the most. These disparities exist largely due to the mechanisms of capitalism and its neoliberal policies decimating the world’s poor.

Neoliberal policies, that are marked by deregulation, reduction of state intervention in the welfare of its citizens, and increased privatization, have huge ramifications globally on people’s health and the continued proliferation of poverty. The eradication of health disparities will not come about until a radical shift in the economic system and these policies. The very functioning of a capitalist economic system, marked by maximizing profit, produces gross inequality and sustained poverty. This system is a continued assault on the poor. Individual behavior is often ascribed to poor health rather than the larger social issues that are a consequence of this economic system that prioritizes profit over people. These Issues such as racism, subpar working conditions, sexism, unemployment, sanitation, lack of clean water, unviable healthcare systems, and poverty magnify inequities and result in intolerable living conditions with limited ways out and directly impacts health conditions.

The push toward a new system includes the rebuilding of public infrastructure, wrap-around resources available to the poor, and the transferring of wealth from private to the public in order stop the devastating cycles and entwinement of poverty and disease. When there is global recognition of healthcare as a human right and with a commitment to political change that creates this, then healthcare can no longer be commodified and people seen as consumers. Simultaneously, the progressive realization of the right to health can only happen when basic human needs, such as nutrition, food, housing, employment, and essential social support can be met and sustained.

 

Jorge Zárate Rodriguez’s Award-Winning Essay

Our fourth winning essay comes from Jorge Zárate Rodriguez of the Washington University School of Medicine:

The Delmar Boulevard is a main thoroughfare in St. Louis, where I go to medical school, that divides the city north and south. But it does more than that, it is also a remnant of the Jim Crow Era in St. Louis when many residential ordinances were passed preventing black people from renting or purchasing in white neighborhoods. The south of Delmar remains mostly white and the north mostly black to date. The Delmar Divide, as has been described in public health literature, is one of the starkest examples of health disparities: the life expectancy difference for St. Louisans living in adjacent zip codes on opposite sides of Delmar is 18 years.

In order to address health disparities in St. Louis and in the rest of the nation, large, broad-sweeping changes to the way we practice primary care are needed. Preventative medicine has become a hot topic in medical education as means to improve patient outcomes all whilst decreasing the cost of healthcare. However, medicine—as an institution—is not set up for this. To increase access to primary care, we need more primary care physicians. Loan-forgiveness programs for medical students choosing primary care, a re-evaluation of relative value units to more fairly compensate primary care doctors, and tax-deductions and financial incentives for hospitals and clinics investing in primary care and serving the underserved, would all go a long way to ameliorate the situation.

In addition to improving the quality of and access to primary care, we need to address the socioeconomic context that our patients live in. The role of the physician and her responsibility to her patient do not end at the hospital’s doorstep. What happens to our patients outside of the hospital should matter to any doctor claiming to practice patient-centered care. With that in mind, we must call on our fellow physicians and our allied health professionals to fervently advocate for much needed legislation that will impact our patients’ lives—starting with more rigorous gun control and more accountability for police who use excessive force, to ensuring access to health insurance and guaranteeing funding for programs like Children’s Health Insurance Program (CHIP).

As physicians, we owe it to our patients to demand for more protections for them, but a favorable legislative environment is not sufficient. Health promotion should go hand-in-hand with health prevention, and it requires educational interventions starting at a young age and through all levels of education, including adult education, to increase health literacy. Also necessary, is significant investment at the community level to make it easier for people to make healthier choices. Needs-assessment surveys can help determine what each community identifies as most pressing: setting up more spaces for exercise, subsidizing fresh vegetables to battle food deserts, replacing old infrastructure (like pipes polluted with lead), or extending public transportation, for example.

Finally, we also have a responsibility to mentor youth interested in science and medicine, especially from minority backgrounds, since they will be key in helping address health disparities in the future.

 

Mya Roberson’s Award-Winning Essay

Our third winning essay comes from Mya Roberson of the Gillings School of Public Health at the University of North Carolina at Chapel Hill :

My grandmother’s name was Ms. Gladys. In truth, I know very little about Ms. Gladys. I never got the chance to meet her because she passed away at an early age due to complications from diabetes and a healthcare system that did not have space for a poor Black woman. What I do know is that Ms. Gladys had 9 children, with my father being number 8. I also know that she spent the majority of her life working in cotton fields as a sharecropper in the south, like many Black people of her generation.

I think about Ms. Gladys fairly often, now especially as my educational ascension, currently being a doctoral student, puts me in a privileged minority.  I think about how the institutions from which I received and will receive my degrees were built by people like Ms. Gladys, and intentionally meant to exclude people like her and her progeny.

Most frequently, I think about how by the time she was my age, Ms. Gladys had already had several children. At age 21, I had well over $100,000 worth of surgery to excise my endometriosis and preserve my ability to have any children, when the time is right for me. It is a humbling reminder of how far health care access and reproductive justice have come, but also how far we need to go so one does not need a college degree and technical vocabulary to receive the best health care. When I think about the amount of choice and access afforded to me and how that is impacted my life and career trajectory,

I often wonder:

What could Ms. Gladys have been? What would she have wanted to be?

In order to truly combat disparities in health outcomes, we must be willing to acknowledge and confront the historical systems of oppression that have lead to modern day inequities. We must be willing to grapple with the centuries long subjugation of entire populations of people. To ignore history in the context of health disparities is to be complicit. To achieve health equity over the next decade we must interrogate how the histories of the sharecroppers, migrant workers, and the formerly incarcerated perpetuate cycles of inequality.

To achieve such a bold goal, we need a healthcare workforce with the diversity of the communities we need to serve most. We need to foster the pipeline for people from rural areas, women, and racial/ethnic minorities to have an active role in public health and the healthcare system. With a diverse workforce, we need cross-disciplinary collaboration, with the basic scientists working alongside the epidemiologists, working alongside the clinicians, working alongside the policymakers.

When we achieve these things, no longer will entire populations be restricted by their health status or access to quality health care. When we achieve these things, the descendants of people like Ms. Gladys can truly be anything that they want to be, and that is the world I strive to live in.

 

Jordan Wolfe’s Award-Winning Essay

Our second winning essay comes from Jordan Wolfe of The George Washington University Milken Institute School of Public Health:

Just as there are countless forms of cancer plaguing the human population, there are a plethora of different health disparities that we face as well, and just as there is no one cure for cancer, it is unrealistic to expect one straightforward solution for all health disparities either. Instead, the solutions we create must be specific, explicit, and tailored to the population and problem being addressed. One of the most pressing but underacknowledged health disparities that currently exists in America is that of police violence and brutality towards the African American population.

Although not commonly perceived as a public health issue, police violence and brutality has a grave impact on the health of both individuals and communities. Living in a neighborhood where the local police engage in high rates of frisking and use-of-force is significantly correlated with physical health outcomes such as diabetes, blood pressure, asthma, and obesity, as well as mental health outcomes such as depression, suicidal behavior, and severe feelings of hopelessness and worthlessness. Although the African American community makes up only 13% of the American population, they shouldered the burden of 26% of police-related deaths in 2015, 24% in 2016, and 23% in 2017. At an aggregate level, cities with 16% more African American residents experienced 66% more police excessive force complaints. This data points to a public health phenomenon occurring not just at the individual level, but at the community and institutional level, which is referred to as the “minority threat hypothesis”, which proposes that cities with more minority residents employ greater coercive control strategies by the police.

This is not to say that police departments are not making efforts to address the issue and curb rates of police violence. As a matter of fact, many local police departments have instituted new training programs, cultural awareness workshops, and community policing efforts in hopes of forging new and better relationships between police officers and their communities to prevent further violence. What is lacking here is cohesiveness between departments and a national support of their efforts. One solution to this void could be the creation of a mandatory and publicly-accessible community policing portal, instituted nationally through the Department of Justice. This portal could serve as a forum for local police departments to report their innovative strategies and best practices for decreasing police violence, as well as track use-of-force and violence outcomes. In comparison, CMS mandates that hospitals publicly report the rate at which their hospital employees receive the flu vaccine; this is required because workers who don’t receive the vaccine pose a threat to patients, and the hospital should be transparent and accountable for this. Like hospitals, police departments play a major role in their communities and should be held accountable for the impact of their actions on the community’s health. Only once we recognize police violence as a public health issue and treat it as such can we hope to make measurable progress in addressing and eliminating it.

 

Susan Grafstrom’s Award-Winning Essay

Our first winning essay comes from Susan Grafstrom from the University of Minnesota:

My current pursuit of a Masters of Public Health degree at the University of Minnesota and future career plans include reducing rural health disparities and improving the health of rural Americans.   I’ve given a lot of thought to this topic so from my perspective, to eradicate health disparities, two things need to change.

First, the inclusion of representatives on local, state, and national policy and work groups who live and work in rural areas or other areas of disparities needs to be a requirement of any policy setting or program development group.  Too often important decisions are made by legislative, academic or career professionals who may study rural health or other health disparities but have never personally experienced, lived or worked within these areas.  While they may be knowledgeable about their field of study, gathering information, drawing conclusions and making decisions are made in the context of their frame of reference which is mostly urban-centric.  Recently on the radio show Rural Health Leadership Radio, Roger Knak the CEO of a hospital in rural Oklahoma remarked, “You’re not going to change the health of a community at an academic center.”

Second, we will never be able to eradicate health disparities until we have a very clear understanding of the health of those experiencing disparities without the availability of strong statistical information.  Lack of data is problematic for most rural areas and I would surmise this is the same for other areas experiencing health disparities as well.

Specifically for rural America, The County Health Rankings are promoted as a snapshot of how healthy a county is and is referenced frequently as a way to measure population health.  Counties are ranked against one another in each state partly to create a competitive environment to increase health and ultimately scores, but also as a measurement for leaders to utilize in program planning and decision-making. While I do not disagree that this tool is valuable, data for rural counties is not as statistically sound as data for urban counties.  According to the article, “The County Health Rankings: rationale and methods” ¹The County Health Ranking does not promise accuracy in the reliability of estimates, particularly for counties with smaller populations; we recognize that the reliability of our measures does vary.

Second, when good data sources are available they are measured too infrequently to be utilized for responsive population health.  In Minnesota, The Minnesota Student Risk Survey is given to all school districts in the state.  While it has very detailed community, county and state level data it is only done every 3 years and only on the same three grade levels.

Therefore, to eradicate health disparities include the leadership and membership of individuals part of the disparity and eliminate data deserts which will provide city, county and regional decision makers with accurate information from which to measure health or to set health programming and policy.

 

1. Remington PL, Catlin BB, Gennuso KP. The County Health Rankings: rationale and methods. Population Health Metr. 2015;13:11. doi:10.1186/s12963-015-0044-2.

 

AcademyHealth Disparities Interest Group Student Essay Contest Winners

In December 2017, the AcademyHealth Disparities Interest Group sponsored a student essay contest prompting entrants to respond to the question “What do you think must happen over the next decade to eradicate health disparities?” Numerous entries poured in and 9 winners were selected to receive a free student membership to AcademyHealth. Over the rest of the month, the winning entries will appear on this site in no particular order. So stay tuned and check back often.