A particular challenge to overcome in efforts to achieve health equity in diverse patient populations is comprehending the needs of underserved communities. To that end, Karen Winkfield, MD, PhD, a professor of Radiation Oncology at Vanderbilt University Medical Center, Ingram Professor of Cancer Research at Vanderbilt Ingram Cancer Center, professor of Medicine at Meharry Medical College, and executive director of the Meharry-Vanderbilt Alliance in Nashville, Tennessee, who delivered the keynote address at a recent symposium on health equity held at Cleveland Clinic’s Taussig Cancer Institute, challenged the notion of “community outreach,” a term she said indicates one-way communication. The first task is to find out what these communities need, she observed. This requires going into communities—often hard-to-reach communities—in person and talking to people where they live. Not one-way outreach, but bidirectional communication.
By going into the communities that lack equitable access to health care resources, Winkfield discovered how varied, and often obvious, the barriers to access are. Such social determinants of health (SDOH) can be as uncomplicated as lacking transportation, sufficient food, or time to travel to a hospital. The barrier could simply be where someone comes from or what they look like. Winkfield mentioned the time she spent working at a Harvard University–affiliated hospital and asked rhetorically, “Why did we have less than a 4% uninsured rate, yet people weren’t coming into the hospital where we had more than 400 cancer clinical trials ongoing?” The answer: “Because access goes beyond just having insurance.”
Among SDOH, shortfalls in medical care represent a minority contributor to poor health and premature death, while other factors, such as malnutrition, social characteristics, and health behaviors—and the interconnection among these factors—exert larger influences. Therefore, a purely medical-focused approach to health equity is doomed to failure, because success requires a holistic approach to removing barriers to health.1,2
Winkfield gave the example of her husband, for whom she was caregiver for many years prior to his death. He was a well-educated Black man who was knowledgeable about his own body and his own tolerances to treatments and medication. His self-knowledge was consistently ignored by clinicians who failed to take him seriously, with devastating consequences for his health. This may help explain why cancer mortality in Black Americans is so much higher than in other racial groups in the United States even when their cancer incidence is not.3
Winkfield described her work in rural North Carolina, where, she noted, 6 hospital systems in rural communities had closed in the previous 10 years. In fact, she reported, 20 counties lack pediatricians, 26 lack an obstetrician/gynecologist, and 32 lack a psychiatrist. Additionally, only 3% of the state’s oncologists are based in rural areas. With that in mind, she noted, when a patient is late to an appointment, it may be worth finding out why before cancelling and rescheduling. Maybe it took them hours of travel time and multiple modes of transportation. Maybe they couldn’t control the fact that their second bus was late. And maybe their poverty and their lack of access to education meant they couldn’t fill out the paperwork once they scheduled the appointment.
Based on their experiences, Winkfield and colleagues have written a document to provide guidance in achieving health equity.4 It was originally intended to examine health equity for cancer care, but this guidance may be applied to nearly any treatment area. The authors offer specific recommendations, a central component of which is the role of patient navigators. The navigators, who are often residents in the communities in which they work, assist patients and their families and caregivers in overcoming barriers to medical care and self-care. They keep track of patients to make sure they are able to access care and not get lost in the various health care system domains that even sophisticated users can find overwhelming.4 The framework also focuses on working with payers to obtain claims data indicating gaps in care and to apply that evidence to programs that can help close those gaps. Another recommendation is to develop “health equity scorecards” for health care systems to promote awareness of equity issues and create accountability for successful implementation of equity programs.4
The actionable framework publication contains specific recommendations across multiple domains from education to funding and from internal evaluations by health systems to staff training and implementation of best practices.4 These recommendations and the overall approach that Winkfield promotes are based on human engagement and meeting with people and local organizations. The challenge of health equity is not just about income, class, race/ethnicity, education, geography, and culture. It is about all of these factors, the ways that they interact, and the structural barriers constructed, often deliberately, to keep certain groups of people away from resources.
KAREN WINKFIELD, MD, PHD
Executive Director, Meharry-Vanderbilt Alliance
Professor of Medicine
Meharry Medical College
Ingram Professor of Cancer Research
Vanderbilt Ingram Cancer Center
Professor of Radiation Oncology
Vanderbilt University Medical Center