Hiding in Plain Sight Whats Missing in Health Equity

compared to

white americans in the united states

there are

twice as likely number of african

americans

who will die from diabetes also

if you look at rates of diagnosis of

breast cancer

you’ll find that african-american women

although diagnosed at the same rates as

white women in the u.s

they are 40 percent more likely to die

when we look at rates of cervical cancer

in the united states

compared to white women hispanic women

are

60 percent more likely to be diagnosed

with advanced stage cervical cancer

why are these things important they’re

important because they affect

each and every one of us in some way

shape or form whether or not you belong

to any of those ethnic groups i am dr

kerry norris

i am the chief of health policy and

administration at the fulton dekalb

hospital authority

and i have worked on this for various

years over 17 years

health disparities are plaguing our

communities but what i propose

today is that the answer is hiding in

plain sight

let’s talk a little bit about how to get

to that answer

so we see various causes of death

throughout the united states these are

all the leading causes of death and when

you look at this you may say

oh well those all look like things that

are preventable they are

and with the work that we can do

together to address

the lack of prevention that we have to

also address

behavioral risk that people continue to

take

to also look at family history and

genetics of what people inherit from

each of their family members

and to also think about persons

environment

did you know that where you live

dictates whether or not you live

or die more so than your family history

your zip code is more important than

your genetic dna

think about that and think about where

people live

and how they live and how that affects

what they have access to

or what they don’t have access to

we also have to think about when we talk

about access

just giving a person insurance or giving

them transportation

is not enough access is a plethora of

things that have to work

together to form the in

the most perfect environment

for the person to get all that he or she

needs

also we’re going to talk about competing

interests

that means if i know that i have been

diagnosed with diabetes

and my insulin costs a lot of money but

i’m also thinking about what am i going

to feed my kids

how am i going to pay this light bill

and i’ve been sick for several days and

so i’ve missed some days off work

then how does that affect whether or not

i can actually

purchase my insulin and take care of

myself so when we have these competing

interests and i have to decide between

feeding my children and actually being

able to

move forward and take better care of

myself and stick with medication

adherence

then we really have to think about how

people are making these decisions and

what it is that they have to do when

they’re making these decisions

so here we can see across various

disparities and across various things

such as blood pressure

diabetes and stroke african americans

are more likely to

die at earlier ages than any other group

in the united states

we also have higher rates of actual

diagnosis why is that

let’s talk a little bit more about it

most people think when we are addressing

those disparities

and they think that when we are looking

at

gaps in access and gaps in health care

that the answer is equality just give

everybody the same amount of access just

give

everybody the same pair of shoes and it

should work

well as we know that doesn’t work and

this is the work that we’ve been doing

for several years

good work nothing to knock any of the

past researchers who’ve come before and

who’ve

done some really groundbreaking work

equality doesn’t work when it comes to

health disparities

we’ve got to think of it very very

differently

what works is equity if you see in the

picture

on your right hand side you’ll see that

with equity

you meet the person where they are to

ensure

that they have the same viewpoint to

ensure

that they have equal footing and that’s

what we need to think about

when we talk about equity but i propose

that this is a really good model

but there are some issues there as well

and the answer and the solution again

to health equity is in that picture but

it’s hiding

in plain sight

so what is it that we don’t see in the

picture

dr arlene geronimous out of the

university of michigan has stated

the stressors that impact people of

color are chronic

and repeated through their whole life

course so i want you to think about that

not the life course of oh when i become

an adult

now i have these bills i don’t want to

be a child anymore oh my aching back

none of those things but more so

when you are in your mother’s

belly whatever stress she experiences

you are subjected to that exact same

stress

and so as you can see here

stressors affect all parts of the body

system

and if a woman is pregnant and she’s

carrying a child there’s no way

that stress doesn’t have an effect early

on

on the fetus on the baby and then

it becomes something that leads them to

early disease

and early death

your body systems are stressed out

any type of trauma any type of chronic

stress and i’m not talking about just

atlanta traffic

we know that’s stressful and you find

ways to get around that

but let’s think about again you’re a

single parent or you’re paying bills or

you live in poverty or you’re trying to

get ahead

simple things you can’t feed your family

everybody’s always talking about all of

this great nutrition stuff and

go organic and buy organic and let’s get

it together and do better with our

nutrition and more physical activity

if i live in a neighborhood where it is

not safe for me to exercise outside

that’s an issue

there’s a problem if i don’t have

access to fresh fruits and vegetables if

i don’t have the money

to purchase fresh fruits and vegetables

it becomes an issue and a problem down

the road that then presents itself

in various forms of disease and later on

possibly disability or death

so what i want you to think about is

something that dr jeronimous proposed

which is called the weathering

hypothesis think of this tattered house

as the body of yourself

or the body of a parent or mother who’s

carrying a child

the storms of life continue to come

the challenges of life continue to come

and we have

absolutely no control over those things

bad things happen

all the time but when it’s chronic

and when it continually happens to

people

then we see that what happens is this

tattering it tears away at your very

frame it tears away

at your very being from your mental

health all the way down to your physical

health

so think of this house as your body

think of this house as the body of a

woman who is carrying a child as

as it tatters away at her and

the paint chips the shutters fall down

the roof has a leak you know the floor

the floorboards are lifting up then i

need you to consider

that all of those things are also

affecting any child that

she is carrying and you are subjected to

stress and trauma

in utero so before you even are

born these are the things that you are

dealing with

and that puts you at risk for early

death

and early disease which is what we see

in a lot of vulnerable populations and

minority populations

let’s move on when we think about

trauma again we’re still talking about

the child

we’re thinking about trauma that happens

to a parent let’s say a parent’s in an

abusive relationship

and they’re being physically or

financially abused

the mother’s pregnant she’s enduring all

of this

the child is experiencing trauma early

on

and then when the child is born they’re

then

experiencing the trauma of the household

the constant fighting the arguing the

fear

the anxiety that they develop all of

these things

and so it leads to mental health issues

which lead to physical health issues it

will manifest itself

physically and so consider that

as the child goes from birth to death

you get an early death because of the

exposure to trauma

constant complex compounded trauma

one on top of the other is not helpful

the effect of the stress on your body

leads to early

disease and early death

so when we think about that and we think

about this childhood trauma

and the long-term impact lots of people

have studied this

if you’ve heard of aces it looks at

traumatic events in a child’s life did

you lose a parent did you lose a

grandparent

were you sick early did you grow up in

poverty were you sexually abused

did you suffer any other type of verbal

abuse

in your household did you watch a parent

be abused

in the household so these are all things

that and we’re talking about

children who are still developing

mentally and physically

and when they are in that position and

they’re learning

fear and that fear is memorized in their

cells

and that fear is encapsulated in their

body

with no release and no way of knowing

how to

cope because we as adults don’t always

know how to cope

then again it sets in

it starts to become a problem with their

mental health where they may

develop ptsd you may have some type of

depression

you may have some anxiety disorders

things of that nature

which then lead to hypertension because

you’re always in this

state of anxiety and you’re always in

this state of oh my god what’s going to

happen

next and when that happens to you your

blood pressure shoots up when your blood

pressure shoots up then you’re at high

risk for diabetes

heart attack stroke you see where i’m

going with this

it’s important to pay attention to this

and so we see the common causes

we see that children who experience

trauma

are twice as likely to develop

depression and three times more likely

to develop anxiety

so i also want to talk a little bit

about access

because the access in and of itself for

children

of color there’s a disparity that’s

there as well white children are more

likely to have access to the mental

health treatment

early on to learn how to cope and to get

the intervention that’s needed

so that they don’t have some of the

early death

disability and also disease that we see

a lot in communities of color

so here’s what i want you to consider

again here we are with this equality

versus equity model

did you see what changed the

final picture shows that they changed

the fence

so it’s not wooden it’s a link chain

fence now

what’s the issue there they’re still

on the outside who thought that this was

still a solution

so what’s hiding in plain sight is the

fact that

in all of these pictures you are going

from

everybody’s equal we’re going to give

everybody the same box

to we’re going to meet the need of the

people

by giving them boxes that put them at

the same level

still doesn’t work and they couldn’t

figure out why

that doesn’t work but we’re meeting the

people with what they need if it’s money

we give that if it’s food

you know we have these farmers markets

and great interventions that are going

on in the community

if it’s physical activity we’re coming

up with various

programs in schools and in communities

to get people walking safer routes to

school

all kinds of great things nothing should

be taken away from those programs

but again the part that is missing is

they’re still on the outside of the

fence nobody’s addressed

the mental health issues nobody’s

addressed

that tattered house

that represents the child

who has been through enough trauma and

stress by the time that they’re five

or six without coping mechanisms

that they don’t know what to do and

they’re already on this life course

of having early death early disease

disability

is it fair is it right absolutely not

even if it’s not directly you it’s your

neighbors it’s your co-workers

it’s your employees for your company

it’s going to cost you a lot

in insurance it’s going to cost you a

lot of sick days

it’s going to cost you a lot of

productivity

so i think that when we look at these

pictures we don’t take away from

the models because of course everything

is stepwise what we learned

should be stepwise we should learn

from past examples past models things of

that nature

but what’s missing is the mental health

piece so i propose

that we go with what i like to call the

mr model

i took all the people out because people

were arguing over these pictures

what color are the people are they peach

are they brown

are they it doesn’t matter what matters

are the actual concepts what matters

is how the concepts are linked and

how we put those things together to then

address

what’s going on in communities so in the

mental health aspect

it would require that we address mental

health early on

you teach kids coping skills early on to

deal with

stressors and how to cope and how to

address

self-soothing works my grandson does it

he’s seven

sometimes he gets in trouble in class

because he goes to sue the other kids

because he wants to get up and say are

you okay it’s all right just breathe you

know things that his parents have taught

him

for when you know he’s stressed or

things are a bit much

for him that can be taught children know

how to meditate

they know how to center themselves and

be quiet and focus on their breathing

and everything else you have to teach

coping

you have to get mental health help

before that first

episodic break before they’re 19 or 21

and away at college or at their first

job and

there is a major break-in and someone

has to call you because they’ve been

admitted somewhere

you have to think about integrated care

every time you go for any type of

physical care

they should be checking on your mental

health and i mean something beyond that

one question they ask

all of us have you been sad the last 30

days

lady i’ve been sad my whole life what

are you talking about

because if it’s chronic stress and

chronic depression

you don’t see it as other people see it

you’re not gonna say oh that’s

depression you’re gonna say that’s been

my life my whole life

how’s it any different so think about

that

socioeconomic status sure

people can get great jobs they can

become educated they can get

insurance and access but if you are

not creating workforce development

programs

in those communities that are still

behind then you’ve got some work to do

transportation having access to get to

the doctor

or putting clinics in neighborhoods so

that people have

the access that they need so that goes

hand in hand with the access piece

and the basic need for housing

if people have a home they are more

likely to do better

they can focus they can concentrate they

can

get their actual insurance cards and

everything else at their address they

can receive services

they can have access to whatever

resources are in the neighborhood or

available to the neighborhood

i want you to think about this mr model

which is named after my son

we are our own study and

i want you to think how this moves

equity forward

for the mental health piece at earlier

stages in early intervention

and so the next time someone talks to

you about health disparities or anything

else i want you to say this to them so

right now we’re going to do something

i want you to look at your neighbor and

say neighbor

neighbor okay

i’m not feeling it i’m not hearing it

loud enough so we’re going to change

that we’re not going to say neighbor

turn to your neighbor and say mister

can i get some health equity

that is how you’re going to remember

this model mr can i get some health

equity

and for that i thank you for listening

today

you