Dr Clyde Yancy: Health Inequality Is Rooted in Our Community, Policy

Clyde W. Yancy, MD, MSc, of Northwestern University’s Feinberg School of Medicine, explains the connections between health care equity and advances in treatment for heart failure and how the United States' policy and science agenda can address them.


You are this year’s recipient of the Chairman’s Award at a time when 2 of your major areas of focus—health care equity and advances in treatment for heart failure—are at the center of the policy and scientific agendas, respectively. Can you discuss the connections between these 2 priorities and how the nation’s policy and science agenda can address them?

We start with the issues of health equity. From the lens of the American Heart Association, we've been on easily a 20-year march, starting with early descriptions of cardiovascular disease disparities–-fairly rudimentary trying to really understand the vernacular and have the definitions correct. But as time evolved, and we realized that, particularly through our quality improvement programs, we were able to demonstrate the ability to narrow some of these gaps.

Where we are now is slightly pivoting towards a threshold where we can achieve health equity. I'm pretty enthused about that, because it means we're no longer just making a description of these important differences between groups of people, but we're trying to find a path that we can navigate to get to a different level.

Now, let me go from that introductory statement to something more explicit. So, part of what we will do, especially in our health equity session, we had a very important call early this morning to clarify this, is to generate a fierce sense of urgency about the necessity to target health equity. Why? Because for the last 20 months, we've seen what happens when health is inequitable, we've seen the price we've all had to pay, we see the burdens that we still carry, the suffering that still goes on.

We've learned the hard way that the only real luxury we have in life is health. And the absence of health in any one of us, threatens the health of all of us. And so we have to be very clear that achieving health equity is not for them or that group or those, but it's for everyone, because we all pay the price for the absence of health equity that disproportionately affects one group or another.

Whether it's related to economics, whether it's related to social justice, whether it's related to how we enjoy engaging and experiencing life, it's pretty clear that the inequities drive a lot of the friction, drive a lot of the difficulties.

Now, how does that intersect with heart failure? The session that I'm moderating on Sunday, is intended to capture some of the newest dynamics in heart failure, and really open up an opportunity that can best be described as heart hope, not heart failure. The data taken collectively, for someone that's been in this space for 31 years, really are the most persuasive, the most profound data we've yet seen.

So, how does that then intersect with health equity? Because you would say, well, there you go, use these great drugs and everybody gets better. No, because now we have to consider access to care. Access to care wasn't accounted for in the first iteration of the Affordable Care Act, because now we're talking about access to medicines, we're talking about making medicines affordable, we're talking about helping patients avoid financial toxicity and having to make choices between living expenses/medical therapies.

Again, that's not hyperbole, we will share patient testimonials in our session that literally identify the struggle that patients have that seemingly look like they're doing okay, but trying to apportion their limited resources for health care, for transportation, for food, for housing. And so bringing on new therapies, yes, dramatically effective, but understanding it comes at a cost is another stress test for our community health.

How many times do our communities need to fail the stress tests before we realize that the root cause of the ill health, the inequitable health across our country, is rooted in our community. It's rooted in policy, it’s rooted in the basics of education, economics, housing, nutrition.

We can look the other way because those problems are too big to solve, but they will continually confront us with yet another failed stress test. COVID-19 was the big failed stress test. The new therapies that are coming out will be yet another failed stress test unless we can find a way to generate equity–in this case, access to care. But it's not just financial.

Think about what needs to happen with health literacy. Think about how important it is for patients to have a full appreciation of one, their diagnosis, 2, their therapy, and 3, their interaction with the health care system, if we don't overcome the barriers that are present because of the absence of health literacy. We will once again perpetuate these inequities.

But we're not done yet. Because if we think about what really happens in the vulnerable communities, we identify that the first insult, and I'm using that word deliberately, is in childhood. When we deal with poor maternal health, when we deal with children who are not able to have a healthy diet, who transition too quickly away from a mother's milk, when we deal with children who are not able to have quality education. The health characteristics of many children are set by the age of 6, and everything after that is catch up.

Heart failure, per se, is a public health problem that begins with the adverse distribution of the social determinants of health. That is to say, when you live in communities with poor access to nutrition, poor economic opportunity, poor employment metrics, poor educational advancements, you're setting up the substrate that predisposes to hypertension, obesity, diabetes, and what are the major risk factors of heart failure, hypertension, obesity, and diabetes.

We will continue to struggle with heart failure until we can deal with some of these more disturbing root causes that are not couched in biology, but couched in sociology and public policy.

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