Dr. Miguel Ruiz
Appearances
Health Chatter
Health Disparities
At the level of the country, you look at a map of the U.S., very stark differences in between different regions of the country about a baby that is born, how long it's going to be expected to live, based on where you live, based on the color of your skin. In the Twin Cities, for example, just to bring it local, healthcare, I mean, life expectancy difference in between
Health Chatter
Health Disparities
Let's say a few blocks west from the hospital where I work in the Frogtown area of St. Paul, just north of I-94. You compare life expectancy of the community living there with the life expectancy of individuals living three and a half miles going west just before you cross the river. In that neighborhood, also north of I-94, just by the University of Minnesota, 13 year life expectancy difference.
Health Chatter
Health Disparities
Wow. In the very core of our cities. So why? Why that stark difference? You know, many of our inner cities in the US have life expectancies in certain neighborhoods, similar to life expectancies in Haiti or some other countries, limited resources countries. And that's a reality in the very midst of our society in our country. So why?
Health Chatter
Health Disparities
Well, because if we are talking about what are we going to do about it, we need to figure out what are the... What are the causes of disparities? What causes disparity? What causes health?
Health Chatter
Health Disparities
And something that I think many people are not aware, because we believe health is all about healthcare, many people are not aware that actually the medical care we physicians provide, our care system providing medical care, accounts for 15 to 20% of the health of a community.
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Health Disparities
Again, the care with authors within, we are making the big difference here, but we need to be humbled by the fact that what we do basically is creating the health of the community for no more than 15 to 20% of the health of that community.
Health Chatter
Health Disparities
So the question is, what else are the determinants of the health of the community? And that's back to our social determinants of health. So it is those economic and social factors, is the environmental, the neighborhood, the safety, the ability to have
Health Chatter
Health Disparities
clean environment with less pollution, the ability to have parks where people can exercise safely, the health behaviors of these communities and individuals. Those are the main contributors to the health of a community.
Health Chatter
Health Disparities
Thank you, Barry. I think you bring up very important points and obviously coming from your own experience, a realization that, boy, this is a challenging area to tackle today. and yet is actionable. There are things that one can do that are specific and that make a difference. I think COVID-19, I think this pandemic has really given us another view of the
Health Chatter
Health Disparities
of the impact of this social- It was a wake up call. Totally. I mean, the impact of the socioeconomic and educational level and so forth. We saw clearly that Latino black were not only affected more by infected more than whites, but also got sicker and had higher mortality.
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Health Disparities
So a lot has gone into why, and I remember reading a study from Harvard, looking at their population in Massachusetts, in which they clearly identified for the Hispanic Latino was the fact that they were living in overcrowded houses with multi-generational members of the family.
Health Chatter
Health Disparities
meaning children that were going to school and going out with elderly parents who were living under the same roof and without little ability to do more isolation when one was infected, with less health insurance to go and be tested, with perhaps less means to drive to a testing site, that somebody who may have access to a car.
Health Chatter
Health Disparities
And also with some of those middle-aged individuals in that same house working in a meat processing plant where high noise requiring to shout and scream to communicate also contributed to higher transmission. And then you look at the black community living in high-rise apartments using more public transportation, and they identified all these
Health Chatter
Health Disparities
totally socioeconomic factors that made a difference into and obviously with under higher rates of underlying comorbidities diabetes and pulmonary diseases that place individuals at higher risk for complications from covid so just to give you yet one more in case we didn't have enough one more view and taste of how these factors do impact uh these uh these communities uh and who are um
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Health Disparities
been marginalized and who are at a disadvantage. So I think, glad that you mentioned Barry, the issue of cultural competence, because, and again, one of the factors for COVID was new arrivals. You talk about the new waves of people arriving for the Hispanic Latino newcomers have not only no connections in the community to know where to seek care, but also no health insurance.
Health Chatter
Health Disparities
The Hispanic Latino is the most uninsured community in our country. therefore delaying care. I had so many cases during COVID-19 coming to the hospital with an advanced case of COVID with complications, having to be intubated in the medicine department because they were not able to be tested because they didn't have the
Health Chatter
Health Disparities
the health literacy to be able to understand where the risk factors of the symptoms were. But what can we do? And you mentioned the word cultural competence. And I think I have a bit of a special feel about that concept because in my mind, I prefer to use the term cultural humility.
Health Chatter
Health Disparities
And just to make the point very, very, very quickly, the one aspect that I don't like about the term cultural competence is that the word competence assumes some degree of mastery, of expertise, of arrival. We got it. We are now incompetent.
Health Chatter
Health Disparities
where I think it's very important to realize from the get-go that we will never be able to really understand a different culture and community to ours to the degree that we are competent. Of course, absolutely, one has to study, learn, talk to the community, really get as much knowledge and understanding of that group of people
Health Chatter
Health Disparities
But I think with the humble approach of always going with the desire to know more, to have a healthy curiosity, seeking to understand before we try to be understood by them. And I think that's something that we as healthcare providers need to have very clear. We need to really understand.
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Health Disparities
put our ideas and our best ways in the back burner and become students of our patients and declare, I don't know, I need to know, I want to know, help me know what matters most to you, what's most important to you, how do you think, why do you think you are sick? What do you think is causing this problem?
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Health Disparities
really trying to get into the narrative that they are living in so that you can, from there, start to develop some approaches to helping them. And of course, also to always be conscious about the healthcare, the power differentials. The fact that many individuals who maybe may have a low English proficiency and thinking about the community and more familiar with the Hispanic Latino community,
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Health Disparities
there is this huge differential between providers and patients that we need to really be very creative about thinking, how do I equalize this encounter in a way that I'm going to be able to connect with this patient so that I can understand how to better help them as opposed to just trying to think that I am the one who knows how things should be done.
Health Chatter
Health Disparities
Yes. If I may say something about that, you're right. And yes, we don't have enough BIPOC providers to care for our BIPOC communities. And unfortunately, recent report in the New England Journal of Medicine, again, in the last 40 years, the number of black doctors, male black doctors in the US, not only has not increased at all, but has gone down slightly. 40 years.
Health Chatter
Health Disparities
So studies, I just read a recent study which showed that if Black patients were cared for by Black doctors, they estimate the disparity in outcomes, the health of cardiovascular outcomes, the disparity will decrease by 19%, by 20%.
Health Chatter
Health Disparities
The reality is we don't have enough BIPOC providers, but the reality is we need to do, that's one of the many things we need to do, is we need to advocate for more physicians of color coming into medical school, especially from those communities that are the most underrepresented, the black community being one of them.
Health Chatter
Health Disparities
So that is something at the level of policy and at the level of advocacy that we need to advocate for, because most people prefer to be cared for by a provider who looks like them, who may have a better understanding of their culture, or who may speak their language.
Health Chatter
Health Disparities
It's an issue of trust. There is something there about, I see you, I think you can understand me because I see you from a similar background. But you are right, Clarence, that that is not the only solution because that's going to be an impossible target.
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Health Disparities
We work on it, but what do we do in the meantime until hopefully one day we get there where we have our healthcare providers representing the same diversity of the community they serve. But you know, today, human resources and medical groups and clinics and hospitals
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Health Disparities
At least my hospital is tracking very closely what is the racial distribution of our nurses, of our, you know, CNAs, of our physicians, of our APPs. We are tracking that. And we have established clear benchmarks that we want to accomplish because we want to move the needle on this area.
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Health Disparities
Because it's an actionable area that we can do something about that we think is going to decrease disparities and improve it. the health of our community. But yes, you're right. We need to really get to the point of trust and care, even when we have racial and linguistic issues incongruity or despite differences.
Health Chatter
Health Disparities
And that's the importance of many, I mean, we could talk forever about what things we could do. I can tell you what we can do, what we are doing in my hospital and in my medical group. But I mean, absolutely, you need to use medically trained interpreters when you are seeing a patient who is not able to speak English. I will say, when I'm not able to speak Somali,
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Health Disparities
I need to get a Somali interpreter to help me care for my patient because I don't speak Somali. It's not that the patient doesn't speak English, it's that I don't speak Somali. I mean, we have to really start thinking, changing our way of thinking and removing the blame from the patient and putting it on us to be able to see what do I need to do to provide excellent care for this patient.
Health Chatter
Health Disparities
I think that's Those are the ways of thinking that will really increase the trust and will send the message that we do care for our patients.
Health Chatter
Health Disparities
Let me see if I understand the connection here. You're trying to connect this with the issue of disparities.
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Health Disparities
Yeah, obviously, as you very well point out, the cause of death of individuals have been the diseases that have been afflicting humanity and societies have changed based on on the evolution of our lifestyle and our environment and the development of antibiotics and treatments that hopefully are benefiting most people.
Health Chatter
Health Disparities
Although again, you think about infections, if you look at HIV, for example, clear disparity in terms of number of new cases of HIV in the US today, clearly higher among black individuals and Latino than white. Why is that? Again, back to the whole issue of education, living environments, stressors of life, and so forth. What we know is that people who are
Health Chatter
Health Disparities
living actually, before we talk about this ACE, correct? The adverse childhood experiences. And now the researchers are talking about the pair of ACEs, which is the adverse childhood experiences. experiences, but also the adverse community environments, ACE, both of them. So even before birth, pregnant women who are suffering from continuous stress because of poverty, homelessness,
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Health Disparities
You name it, you know, issues with drug use disorders, discrimination, poverty, poor quality of environment and so forth. That in utero, in development human, is already being affected by higher levels of stress hormones, cortisol, adrenaline, norepinephrine, and so forth.
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Health Disparities
that baby comes into the world into a situation of, again, maybe homelessness, maybe incarceration of one of the parents, maybe emotional and sexual abuse of one of the parents and so forth. So this is leading to a situation in which by the teenage years,
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Health Disparities
they're already having to cope with that added, as they call it, allostatic load of stress that has been affecting this individual that may have already caused some, through epigenetic mechanisms, some disturbances in their nervous system. And that ultimately we know it leads to premature ageing. and to higher mortality and to shorter life expectancy. So it's there, it's in the society, really.
Health Chatter
Health Disparities
So how do the diseases of our days, to your question of diabetes, cardiovascular diseases, how are they impacted by these disparities greatly?
Health Chatter
Health Disparities
Because if really to be able to eat healthier food, you have to pay more, or you have to have a car so you can buy the food in certain places, or you are living with a food scarcity type of situation because you are in a food desert in a bigger city, in a larger city. Those issues are going to make you more prone to fast food, intermittent food.
Health Chatter
Health Disparities
That is going to make you more prone to poor control of diabetes, of hypertension, and other diseases that lead to cardiovascular death. So that's why, for example, in our hospital today, we are starting to measure food safety on any patient who is discharged from the hospital. Special workers, case managers are assessing these patients' access to food before they leave the hospital.
Health Chatter
Health Disparities
And the safety of it. And guess what? We are finding people who don't have food security. here in St. Paul, okay? And guess what?
Health Chatter
Health Disparities
Well, we have a partnership with Second Harvest or whatever nonprofit organization that can provide and we can do a follow-up and we can, how can we pretend that this patient is going to be worried about getting those medications that have been recommended following their heart attack or following their stroke or whatever else when they are most primarily worried about what they're going to be eating or how they're going to be feeding their children.
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Health Disparities
I mean, we need to start building the house from the foundation, not from the roof.
Health Chatter
Health Disparities
And what we are doing sometimes with our traditional medical approach is trying to patch a sinking boat, and there's bigger holes than the medical problem. And I think basic needs need to be addressed, just to give you an example.
Health Chatter
Health Disparities
Thank you, Sheridan. This is so important. And you are absolutely right. And I think I should have clarified this from the get-go that it's not just about skin color. There are so many other categories of disparity. So thank you for bringing those up. Yeah, it is black. It's a woman. It's poor. is with a family member in jail. I mean, the intersectionality there is just huge.
Health Chatter
Health Disparities
And the result of systemic racism through centuries and generations and generations. So complex. I think something that we, the data you present is based on, back to the point I was making before about the cultural humility, seeking to understand. we need to listen to this community and really hear their perspective on the care they are receiving. So if LGBTQ individuals are perceiving
Health Chatter
Health Disparities
poor care and discrimination, we need to say, yeah, I want to hear you because you're right. Your perception, we cannot say, oh, we treat everybody the same, which is, you know, we have the same standard, the same protocol, the same algorithms. No, we don't. Because even when we do the same things, there is a human essence and there is still the issue of unconscious biases.
Health Chatter
Health Disparities
And there is the issue of discrimination that happens and that is there and is proven and is present. What do we do about it? Number one is we need to listen to these communities. And to be able to listen to them, we need to give them a place at the table. We need to reach out and say, tell us, how are you being cared for? How are you perceiving your care is being?
Health Chatter
Health Disparities
Tell us what do you see the problems are? Tell us how we can help you. Again, a humble approach to, no, I do have developed these solutions to your problem, and this is what we're going to do. No, I go to you and you tell me, how do you think you could be helped better and doing something about what we hear. At the hospital, we have these equity rounds.
Health Chatter
Health Disparities
We have them for a while where leadership, senior leadership, will go to rooms of patients who were in one of those categories, not just people of color, but a veteran or somebody who is, you know,
Health Chatter
Health Disparities
different gender or different sexual orientation or whatever else and try to sit down with them and have a one-on-one conversation and take some notes and apologize on the spot for whatever perception they already in that hospitalization were perceiving as being treated unequally. So I think that's the start.
Health Chatter
Health Disparities
And then obviously at the level of policy, we need to advocate for those policies that are all about equity. And I just, let me remind all of us that equity really is that everyone has the best chance to get the best outcomes possible or be as healthy as possible. Equity is not about we do give everybody the same treatment. Equity is about outcomes.
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Health Disparities
It's how can we have everybody achieve the best health possible. Some people will need this to achieve that. Other people will need something very different to achieve that goal. And that's where we need to customize our care based on what we learn from these communities. So community engagement is very key.
Health Chatter
Health Disparities
And then having those individuals being in patient board meetings and having individuals from those communities who are disadvantaged or have been made disadvantaged be at the table. But not only be at the table, talkerism, but be at the table and have a say at the table, inclusivity.
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Health Disparities
So true inclusivity, not just diversity, but diversity and inclusion, meaning giving these individuals the power to change policy, the power to lead. And that means that some of the folks need to step out of the table to give room for these individuals. And this applies to healthcare, this applies to politics, this applies to school boards, this applies to everywhere.
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Health Disparities
That's, I think, the only way we're going to change the current environment.
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Health Disparities
All right, good, great question. Thank you very much for having me here with you. And I'm glad this is going to be a conversation because as you know, some of these deep questions don't have a clear cut answer or a simple answer.
Health Chatter
Health Disparities
Thank you so much for the conversation. And great. Thank you for your also. I've learned today quite a few things from you, too. So thank you so much.
Health Chatter
Health Disparities
These are very complex topics. And, you know, I'm not sure what has brought this to the forefront now in the last few years. You're right. Disparities have always existed. From the very beginnings of medicine and history, there's been discrimination, disparities, and the forces behind them that have existed. And that is actually...
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Health Disparities
And in the case, even in the beginnings of medicine, we have an increased awareness of how our early fathers in the medical science really, unfortunately, use very racist approaches to care. from the mistreatment of enslaved individuals to the use of these for experimentation to really misconceptions, even in our most prestigious journals.
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Health Disparities
For example, the New England Journal of Medicine earlier this year and in the last couple of years have had some series of articles on racism in medicine and healthcare disparities in medicine. And they go to a historical review of such. So this is not a new topic. Healthcare disparities and health disparities have existed from the beginning. I think many factors go into why now, to your question.
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Health Disparities
I think one of the factors is that we have had a greater capacity to measure. We have been much more focused on outcomes and because of the technological progress and development, we are able to extract data much more easily than we used to in the older days when a lot of the research was much more manual.
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Health Disparities
And now with powerful computing systems, we're able to extract data from electronic health records, which we didn't have before. in a much easier way. Therefore, having access to these metrics very quickly and in a very efficient way. Thus, in terms of the technological, then there is obviously the whole social moment that we are living.
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Health Disparities
And as you can see, obviously the history of our country and the history of humanity has had highs and lows and peaks of awareness of the disparities, racial and otherwise. And as you know, the last four or five years have been very active years for unfortunate reasons on those issues of the injustices.
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Health Disparities
of our society, and obviously with healthcare injustices are at the very core of injustice in general because of the consequences of such. So I think those are two things that come to mind. I know there are probably many others, but there have been scientists and researchers that have been looking into this topic for many years, not just the last few years.
Health Chatter
Health Disparities
Great, great question as well. I think one of the contributors to a greater gap for Minnesota is that the outcomes for some individuals are very excellent. So when you have a gap, the gap is differential in between a health status or health outcome in between two different or three or four different groups. So when one group has excellent outcomes,
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Health Disparities
that makes the gap bigger, even when the outcome for that more disadvantaged group are not worse than the outcome for that such a group in other parts of the country. So I think that's one of the contributors.
Health Chatter
Health Disparities
And of course, when we are going to talk about closing the gap and about eliminating or decreasing disparities, what we want to do is to bring the lower group up to the standards and the outcomes of the upper group. or the more advantage group, not lowering that higher group into the lower.
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Health Disparities
And just a fact that I think hopefully will lead us to also talking into what we call social determinants of health is the fact that, for example, Latino high schoolers have the lowest graduation rate in the country. That is Latino... students in Minnesota have the lowest graduating rate from high school in the US.
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Health Disparities
So we have these pockets of inequity, to call it somehow, in certain groups for reasons that are I don't think completely understood, but are a painful reality. How can we have such a good performance in so many metrics and indexes as you refer to, Clarence? And yet we have this very painful realities of specific groups being really very behind compared with even the rest of the country.
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Health Disparities
Yeah, no, that's great. I think the question is no longer, do we have healthcare disparities?
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Health Disparities
The answer is very clear. And, you know, it's very clear to most people, to most stakeholders. There was a time not that distant in the past where some people were very skeptical about, yeah, about the disparities because hospitals and medical groups were providing good care to everybody who comes through our doors. And there was that perception of we are doing the best we can with everybody.
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Health Disparities
We don't... quote C color and so forth. And really showing this data has been very important to leaders in healthcare to say, actually, yes, you are doing your best, you think, but you do have healthcare disparities in your system. And these are the numbers. So now the question is what are we going to do about it? Because we do have those disparities.
Health Chatter
Health Disparities
And perhaps we do make a parenthesis because I think the answer to that question really requires that we have clear concepts about some of the terms that we use here interchangeably. One of them is what is health disparity? And basically health disparity is a difference in health, in health status, in outcomes.
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Health Disparities
that is in between groups, that is closely linked to social, economic, environmental, and so forth disadvantage, okay? So it's about health outcomes are different in between two groups. Then we have healthcare disparities, which are basically the difference in accessing care, in the quality of the care, in the use of the care, in having insurance or no insurance.
Health Chatter
Health Disparities
So because I think when we talk about what can we do about the disparities, we need to know what the problem is. There are health disparities. There are now also health care disparities. That is, the way we provide medical care for patients has some inbuilt disparities. And then what is my area of impact? I think each one of us has to ask the question, what can I do?
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Health Disparities
Because what is clear is that some of these social, economical, environmental disadvantages, these are huge policy, political, and societal issues that one can feel very important to do anything about. And then you can say, well, there's nothing I can do to change this huge monster of injustice. And basically you give up and just do nothing.
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Health Disparities
But the question is, what can I do where I am, like you with your podcast today, to raise awareness, to bring the points, to make a call and appeal for change? And I think I can perhaps speak a little more about what can we do from my position in terms of being within healthcare about some of those healthcare disparities. But just to throw a couple of numbers, if you give me 30 more seconds here.
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Health Disparities
Health outcomes, health disparities. One of them is for example, survival or life expectancy. I mean, what other health outcome more final and more direct that how long a human being lives. So life expectancy, a clear gap in between black and white, people of color and white.