Imagine a large group of patients in the same town enter the hospital with similar symptoms likely resulting from water contamination. What is the role of the clinician? While treating the patients’ symptoms is a primary concern, the clinician also needs to address the water supply of this town. Similarly, in the wake of the Covid-19 pandemic, we saw how one’s socioeconomic status could lead to an excessively high number of deaths. The medical field has seen gaping disparities in the accessibility and quality of care for many, which is contributing to the declining health for many. These disparities need to be addressed before they flood out of control. With this piece, I hope to not only shed light on the health disparities that plague our medical system, but also on what can be done to fix these issues.
With the abundance of scientific research published by academic institutions, the very data we use to develop drugs and medications may be skewed due to unfair systemic influences. Starting in the 20th century, researchers conducted studies that excluded marginalized groups while also using those same populations for unethical studies. Some of these studies were compared to practices examined at the Nuremberg Trials, which highlights the magnitude to which the system was flawed. In 2018, our healthcare spending accumulated to about 16.9% of our GDP, while the next highest of the OECD countries was Switzerland, with about 12.2%.
However, this increased spending somehow led to an average life expectancy of 78.6, while Switzerland was five years higher at 83.6 years. Creating a perfect healthcare system is an imperfect science, but when the U.S. spends one of the highest amounts on healthcare per capita, yet consistently performs lower than other developed nations on health metrics like life expectancy, chronic conditions, and obesity, it is clear that something needs fixing in our system.
Currently, there are blatant gaps in our healthcare system in terms of quality, access, and cost, commonly known as the iron triangle. This includes differences in the quality of care patients receive, in addition to their ability to seek out and receive care, which the pandemic not only highlighted but also exacerbated. Widescale recognition of these gaps started about two decades ago with the 2000 Surgeon General report that documented disparities in tobacco use and access to mental health care relative to race and ethnicity. Even before that, in 1984, the U.S. Department of Health and Human Services stated that despite significant progress in health, there are still major disparities in the “burden of death and illness experienced by black and other minority Americans.” The most recent metric for healthcare disparities is the COVID-19 pandemic, which brought to light the fact that people of color did worse across a spectrum of health measures like cardiovascular disease, cancer, asthma, infant mortality, and more. Black women are three times more likely to die from pregnancy-related issues than white women. And the overall maternal mortality rate in the U.S. is about 23.8 deaths per 100,000 live births, while the next highest rate was France with 8.7 per 100,000.
To address the multifaceted issue at hand, areas of unequal care must first be identified, leading to the development of accountability measures that ensure longitudinal change and address a variety of social determinants of health. Fortunately, there are multiple avenues to work towards establishing a more equal landscape. Research groups can improve their transparency and community awareness, in addition to the IRBs that govern these studies, by further working with the population they are studying outside the academic sphere, utilizing a mix of online presence and in-person engagement to expand their outreach, and making sure the goals of their research are known from the start. Research groups and IRBs should work to create more public and diversified awareness of their studies. If they can share their goals with the community more clearly, then this might motivate more people to enroll in such studies, since there is a mutual understanding that this research can bring about positive change in the lives of everyone in the community and beyond.
We should build sustained, reciprocal relationships with marginalized communities, which prioritize participant experience metrics and don’t isolate research goals against participants. Developing these relationships between research groups and communities is a symbiotic association since research groups get more representative and generalizable data which can also lead to more effective methods of treatment. This in turn can help reverse the negative connotations some may have of the medical system and encourage more participation. For example, Fogle et al. demonstrated that increasing community awareness about the warning signs of ischemic stroke increased respondent awareness of the warning signs from baseline by about 80%. This was done through community education campaigns and telephone surveys. In other words, this study shows that direct involvement with the community can have a tangible impact on saving lives, which can be potentiated in populations at risk for certain diseases.
Lastly, we should recognize the connections between research and health inequities. If there is no justice at the foundation of how we conduct research, then our very own stream of knowledge becomes polluted with biases and mistrust. In essence, there is no one solution to solving an issue that has plagued our healthcare system for years.
As a student interested in becoming a future member of the healthcare community, I believe that it’s important to address issues such as disparate quality and access to healthcare now, if we truly want to make an impact. For me, I recognized that starting in my own community was a great platform to create change. Serving as a commissioner on the Rochester Commission for Racial and Structural Equity provided an excellent opportunity to make a difference, as we were charged with reviewing local city and county laws to identify areas that perpetuate structural inequity and determine ways to change them.
Our first challenges were to identify what was causing vast river pollution and explore large scale methods to not only stop this pollution but also promote longitudinal preservation of the river. Before the pandemic, the Rochester area was experiencing positive trends, with a decreasing uninsured rate, safer behaviors observed in Youth Risk Survey, and more. However, there were still large holes to be addressed, with areas of Monroe County facing disparities in race, ethnicity, or socioeconomic status in areas like maternal health and vaccine distribution, according to the New York Community Health Goals, and the arrival of the pandemic only exacerbated these issues. Furthermore, the untimely death of Daniel Prude and the ensuing protests in the area added to the gravity of our work as we tried to address multiple aspects of the issues surrounding racial and social inequality.
After a year of work, our commission published a systematic analysis of the laws and policies currently in place and identified areas for improvement. We developed 5 systemic solutions with recommendations for future legislation, which included creating sustainable economic opportunities in marginalized communities, working to increase cultural competency across organizations, and embed accountability measures in all policies to ensure equity and fairness. Our work is ongoing as we learn from the implemented policy improvements and explore ways to continually improve, based on the changing needs of our city. Implementing similar strategies of wide scale legislative analysis to promote more macroscopic change in our communities is something that I am deeply passionate about and hope to implement across other areas. Policy change can attenuate some of the large sources of pollution in our river, but hands-on work is also necessary to cleaning up.
As shown above, legislative work can bring about large scale change, but it does come with an associated bureaucratic burden. While legislation can be helpful and create change, often it is necessary to take independent action like going to the riverbank yourself and cleaning up trash to see an improvement. Starting college in Philadelphia, a city ridden with healthcare disparities, provided the opportunity for me to become actively involved with addressing healthcare disparities. Philadelphia sees large percentages of their Black and Hispanic populations generally experiencing “poor or fair” health in contrast to White populations. This distinction in health quality may be highly correlated to higher rates of uninsurance which further contribute to the downstream effects of poor healthcare access and quality.
As a member of the Wharton Undergraduate Healthcare Club, I helped create the Healthcare Literacy Clinic. The clinic’s primary initiative is to teach local members of the community about the health insurance system and assist anyone lacking proper health insurance with the sign-up process. Additionally, the clinic partners with other regional organizations that help Philadelphia residents outside of the healthcare sphere to find food, housing, and transportation resources. Determining a method to educate the population proved particularly challenging as almost 1 in 5 Philadelphia residents are uninsured and there is a relatively low literacy rate. Because of these challenges, we avoided the standard “educational” lecture model and instead wanted to engage clinic visitors in meaningful conversations. Speaking with Philadelphia residents provided insight about their time in the area and reasons why they may not have been insured, while also allowing us to guide them to the right resources to become insured.
The Healthcare Literacy Clinic aims to continue this initiative year-round and gather additional quantitative data on the issue to help us focus our approach. Ideally, this will allow us to expand to more clinics across Philadelphia and provide this important service to even more residents. By assisting more residents to enroll in health insurance and/or directing them to the right community resources, we hope to create longitudinal change. Like treating the water supply upstream, determining ways to assist those with adverse socioeconomic influences, can hopefully deter the downstream effects that lead to unequal medical care. It is important to embody the change we want to happen. Grassroot approaches are an equally important method of action to work with members of our community and bring about change. Working with the Penn Healthcare Management Department, we managed to develop more educational materials to distribute which includes information about local and online resources on how to get sign up for insurance, find local health specialists, and mental health resources around the city of Philadelphia.
Despite the growing severity of these disparities and the downstream effect they have on neighborhoods, cities, and the country, starting with small changes in a local community can have an impact. Working with the local government, a health clinic, or determining another way to take action can help. Healthcare is a universal human right and future leaders can help now to ensure that everyone is granted this right. As discussed, there are many populations that do not receive the same care quality as others and need help. It’s time for researchers, and policy makers, and anyone who wants to preserve the universal right to healthcare to address the inequality faced across the nation and help to alleviate the downstream effects of these large healthcare disparities. Large or small, legislative or one-on-one, the actions that we take now can set us on the right track to cleaning up the water supply.
Aaron Anandarajah is a junior at the University of Pennsylvania. He studies neuroscience with a minor in healthcare management and chemistry. In addition to studying traumatic brain injury and neurocritical care, Aaron is also interested in the intersection of medicine and health policy, with what can be done to promote health equity.
Outside of class, Aaron loves to play soccer and basketball, watch and review movies, and try new restaurants with friends.