A wide-ranging discussion sought to bring greater urgency to achieving health equity during the 2021 American Heart Association (AHA) Scientific Sessions.
Sylvia Martin lives in Compton, California, but her health care fate was sealed in New Orleans, Louisiana, where she was born in 1953. It was a year before the Supreme Court ruling, Brown v. Board of Education, started the very slow process of dismantling the South’s two-tiered education system; it would take until this date in 1960 for young Ruby Bridges, born a year after Martin, to set foot in a formerly all-white New Orleans public school. US Justice Department consent decrees would still govern some school districts and Louisiana’s higher education system 30 years later.
The health care system was no less intransigent. Medicare’s creation in 1965 dealt a blow to segregated hospitals, but in the countryside where Martin grew up, there were plenty of loopholes. “We traveled 44 miles just to see a doctor,” she recalled, at the start of a video chronicling patients’ experiences with racism in the health system.
The doctor would see all the White patients first, while the Black patients waited. It would be close to 5 o’clock before the doctor would make his way to the “colored side” of the office. “I’ll take the first 3 of you,” Martin recalled him saying, “And if the rest of you guys can make it through the night, come back tomorrow. And we were there. At 6 o'clock in the morning.”
She is not alone. Martin appeared in a video that ran midway through a powerful session at the 2021 American Heart Association (AHA) Scientific Sessions, “Achieving Health Equity: Advancing Toward Solutions.” The video also featured Bonnie Senteno, who was working 4 jobs to make ends meet when she became disabled from an intracerebral hemorrhage, brought on by high blood pressure.
It took 2 years for Senteno to recover and fully understand what happened. “I would really want doctors to listen, because it it's so important—I mean, I went 2 years, and I can ever get that back.”
The legacy of slavery, Jim Crow laws, and racism that occurs both broadly across society and in daily exchanges has left its mark on the health of Black populations, according to the experts who took part in the discussion led by AHA President-elect Michelle A. Albert, MD, MPH, FACC, FAHA, of the University of California at San Francisco (UCSF), and Clyde W. Yancy, MD, MSc, FAHA, of Northwestern University.
Yancy called for a “sense of urgency” to remove barriers “that are destructing and destroying our ability to have to health equity.” The path forward is multi-faceted; it includes recruiting more Black doctors and developing more minority leaders across health care. It includes serious scholarship in health equity and funding to make it happen. It includes restoring budgets to public health agencies such as the CDC; Sonia Angell, MD, MPH, formerly California’s top public health official and now an assistant clinical professor of medicine in at Columbia University, reminded the panel of the statement from the Rev. Martin Luther King Jr., “Budgets are moral documents.”
Health equity in cardiovascular care. Albert highlighted the AHA’s 2024 impact goal in health equity: “Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality.”
It’s a tall order, but one Albert said is inclusive—it covers not only equity for racial and ethnic minorities, but also for the poor, seniors, rural patients, and the LGBTQ community. Disparities in health are related to racial discrimination, but they are rooted in economics, she said. One quarter Black and Native American Americans falls below the poverty level. “And that is a like a fundamental stressor and driver for cardiovascular disease.”
Harvard’s David R. Williams, PhD, MPH, said the linkages of generations of racism, chronic stress, and lower life expectancy are not to be underestimated. He displayed decades of life expectancy data to show that it took the US Black population until 1990 to achieve the life expectancy Whites had reached by 1950. And the gap between Black and White life expectancy is now widening again, due to COVID-19. Williams said the last time the country saw such a large drop in life expectancy was in 1943, during the middle of World War II.
Even where Medicaid expansion has occurred, it is chronically underfunded in segregated communities. Black youth suicides have climbed, and Black mothers worry their children will have confrontations with the police, causing record levels of stress. The milieu is toxic.
“Everyday discrimination is associated with coronary artery calcification, inflammation, high blood pressure, poor asleep, premature mortality, visceral fat, shorter telomere length, arterial stiffness, incident cardiovascular events,” Williams said. “We can see the adverse negative impact of discrimination on the health of populations.”
Health inequity is so pervasive, he said, that 200 Blacks die prematurely in the United States every day. “Imagine a fully loaded jumbo jet with 200 passengers and crew crashing every day and everybody on board dying.”
Mahasin Mujahid, PhD, MS, FAHA, an epidemiologist from the University of California at Berkeley, said that the “national reckoning” taking place about structural racism comes as the country has lost 750,000 lives, “highlighting the alarming health inequities that we are battling.” Given this reality, scholarship and work in health equity, “can't be performative. People are in despair, people are dying….to really do this work, we need to up the stakes and explicitly call out structural racism and other structural drivers of inequities.”
She warned that the current focus on health equity research must elevate those scholars who have been in the trenches. “This work is certainly not new. But what is unique about this moment is that there are significant resources being committed to this research. And it is important to make sure that these resources and opportunities go to the people who have been doing the work historically, the people who have the rigorous training, and who can do the best science.”
“It is also critical for these resources to go to research teams that include scientists who are also members of the socially marginalized communities experiencing the most pervasive health inequities. And that must include Black, indigenous, and other people of color,” Mujahid said.
Voices of patients. Martin appeared in the video with her adult daughter, Evelyn, who is visibly disabled and walks with assistance, having been born at 26 weeks due to her mother’s preeclampsia. Evelyn shares that she felt doctors listened to her more when she a child than they do now. Medical equipment and supplies come with long waits. Senteno, of Bellflower, California, describes having pennies to her name 2 weeks each month, and says had her doctor fully explained the medical danger she was in, she would have taken her blood pressure medication more faithfully.
Barri Bladon of Long Beach, California, was 39 when he suffered a stroke due to undiagnosed hypertension. He lost his job days before he would have been eligible for health coverage. He’s now studying to be an occupational therapist and speaks out about inequity. “Let's just be honest, if you go to an affluent community, you can get whatever you need. If you have the right insurance, you can get whatever you need. If you have Medi-Cal, which is the state-run insurance, you get what they tell you.”
Powerful responses. Yancy then took comments from discussants, who responded both to the video and to earlier speakers. “It was striking that to see patients in that video, feeling like there are doctors in the health care community [that] do not care about them,” said Carlos Rodriguez MD, MPH, FAHA, of Montefiore Medical Center. “That deeply hurt me—the lack of empowerment in patients, in the understanding of the history and legacy of structural racism that is so deep and far reaching.”
Taking on health equity “in piecemeal” hasn’t worked, he said. “We need multilevel community strategies interventions that are in concert with health care reform, with intentional, direct, positive impact on disadvantaged communities,” along with a realization that more than 30% of the US population is Black and Latino.
Andre' L. Churchwell, MD, FACC, of Vanderbilt School of Medicine, summed things up this way: “The headline is the social determinants of health are the same social determinants for educational success or equity for marginalized group. The social determinants of health are the same social determinants for wealth, acquisition, and growth. The social determinants of health are the same social determinants for equitable justice system and justice equity.
“So, that's the headline,” he said.
Kirsten Bibbins-Domingo, MD, PhD, MAS, an epidemiologist from UCSF, said equity must be “embedded into our standard processes for holding each other accountable.” Not long ago, no one wanted to talk about safety and quality in health care, but now it’s measured and tied to reimbursement. It’s time, she said, to create similar structures to attack inequity, “to really make sure that this doesn't become the forgotten pillar, and that health equity is front and center.”
The patient stories are important, Bibbins-Domingo said, because they cannot be lost amid the broad vision the AHA has set out to achieve. “What we cannot do is have the broad vision let us off the hook for what we absolutely have to commit to within our clinical settings. When patients come into our house, the responsibility for equitable outcomes is ours.”
Although Crystal Cené, MD, MPH, FAHA, serves as executive director for health equity for the UNC Health System, she noted that it’s important that the task of achieving equity not be limited to health leaders in these roles. In that vein, she said it’s important for Black and Latino leaders to rise to positions such as chief operating officer or chief medical officer. Cené advocated for hiring locally, especially from the communities that health systems serve, to be a positive engine in the local economy.
Yancy endorsed the idea of economic opportunity “as a path forward” towards health equity. “We oftentimes believe that diversity is about representativeness, when in fact, it's about diversity of thought, diversity of ideation, diversity of creativity. And we must remember that leadership is where those contracts, where those budgets originate.”
Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, of the University of California, Los Angeles, said he had 3 thoughts: “One, the issue of knowledge and awareness of risk before and after a cardiovascular event; second, the issue of knowledge and awareness of resources before and after a cardiovascular event. And then finally, the availability of and the accessibility to resources before and after a cardiovascular event.”
There are defensive strategies of checking for biases, and positive ones that call for improving cultural awareness. “And that's where you have clinicians actively seeking to connect patients to resources in the community that allow them to have the practical and emotional support that they need and deserve.”
Ovbiagele said that academia needs to highlight the historic basis of what health disparities. As a stroke neurologist, he sees it: counties where slavery existed remain less healthy today, as do areas where redlining occurred. “For over 60 years, we’ve known that these disparities existed, and we can measure them all this way.”
“What I haven't heard so far is the issue of advocacy,” he said. A bill to address health equity has been introduced in every Congress since 2007, which could address many of the issues raised.
Albert, who had been visibly moved by the patients’ stories, told the audience, “I often think about just how we need to just, at first, be human beings…. We just need to view each other as equals, and as human beings. For the doctors in the audience and all caregivers, it is important when patients come to us, to ascertain from them, ‘How can I help you?’
“And then listen, listen deeply, not move into what you feel they should know,” she said. “But first, listen. And through that listening and that silence, magic can happen for the patient, as well as for you, as well as for the population.”