African-American babies born in an economically depressed Northeast Houston ZIP code are more than eight times more likely to die within their first year of life than those born in an affluent neighborhood just a few miles away. Rural women are twice as likely to die from cervical cancer as their urban counterparts.
Health disparities—the ways in which some groups are disproportionately affected by preventable differences in the risk and outcome of disease—aren’t new. But, over the past 20 years or so, researchers, public health officials and healthcare providers have become more focused on understanding the causes of these disparities and finding solutions.
Dr. Stephen J. Spann, UH vice president for medical affairs and founding dean of the UH College of Medicine, said it’s more complicated than just making sure everyone can see a doctor. So-called social determinants of health—race, poverty, education, substandard housing and lack of access to healthy food, transportation and a safe place to exercise—account for up to 80 percent of preventable illness and death.
Health policy can both address and exacerbate disparities. Jessica Mantel, co-director of the Health Law & Policy Institute at the UH Law Center, said policies that reward providers when patients meet certain benchmarks—fewer emergency room visits, for example—could cause physicians to drop patients who don’t follow their advice, even if that is caused by lack of money for medications or transportation to return for an office visit.
Insurance policies requiring high out-of-pocket expenditures mean some patients are likely to avoid seeking treatment, Mantel said.
But she sees a positive side, too, especially from policies that reward providers for keeping patients healthy. “A patient with asthma who lives in a mold-infested apartment, traditionally that’s not the healthcare system’s problem,” she said. “But, now these policies are nudging providers to address these social and environmental problems that affect health.”
The Houston area is a living laboratory for health disparities, and Shainy Varghese’s Stafford clinic sits squarely at the nexus.
Varghese, a pediatric nurse practitioner and associate professor in the UH College of Nursing, says most of her patients are on Medicaid, so they have health insurance. But they often lack health literacy, the knowledge that would help them make decisions about everything from immunizations to diet. She and her staff spend a lot of time on health education.
Nutrition is an issue, both because healthy food is expensive and because many parents continue to serve what they ate as children.
“I explain the importance of green leafy vegetables, but for some of them, it’s rice and beans because that’s what they are used to,” she said.
“ The United States spends far more money than anyone else on health care, and yet we don’t have the best health.”
Varghese’s clinic is next door to the Women, Infants and Children Nutrition Service. Some of her patients receive food stamps. Even so, she said that may not be enough to feed a growing family.
“They fill their children up with chips, because that’s less expensive,” she said.
It also can lead to obesity, Type 2 diabetes and other problems, especially when coupled with lack of exercise, problems too complex to solve with a quick visit to the doctor or nurse practitioner.
“A higher prevalence of diabetes may not be fixed by giving everyone diabetes medicine,” Spann said. “Doctors can’t fix it all.”
They can’t, but the training of future healthcare practitioners is changing to reflect the growing recognition of health disparities.
Sandra Lee is part of that at the College of Nursing, where she is an assistant clinical professor.
Inequality leads to unequal health outcomes, she said, and educators are addressing racial and other forms of implicit bias. For example, Lee developed a module on the LGBTQ community for a nursing course on mental health care, noting the group has higher rates of depression and suicide than the general population.
Another piece of the solution involves building a more diverse health care workforce.
Lee said diversifying the workforce is about more than allowing people to be treated by someone who looks like them.
It also means providers will be able to draw upon their colleagues for a wider range of ideas to care for disparaged groups.
If the goal is to eliminate health disparities, the end is not yet in sight.
“I think it’s a moral imperative,” Spann said. “But it’s also an economic issue. The United States spends far more money than anyone else on health care, and yet we don’t have the best health.”
He is guardedly optimistic.
“I don’t think we’ll solve it overnight, but there’s a lot of low-hanging fruit.”
Access to Care
have no physicians of any kind
have five or fewer physicians
have no obstetrician/
have no general surgeon.