Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

COVID-19 Sept. 9, 2020 update

AMA Chief Experience Officer, Todd Unger, discusses the latest health equity news with AMA's Chief Health Equity Officer Aletha Maybank, MD, MPH, including why health equity can't advance unless there's an understanding first about the context of public health.

Learn more at the AMA COVID-19 resource center.

Speakers

  • Aletha Maybank, MD, MPH, chief health equity officer, AMA

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.


Unger: Hello, this is the American Medical Association's COVID-19 update. Today we're discussing the latest health equity news with Dr. Aletha Maybank, AMA's chief health equity officer in New York. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Maybank, let's start talking about public health, there's been some big news about the 10 essential public health services framework. Can you talk about what's happening there and why it's so significant?

Dr. Maybank: Right. Thanks. Hi, Todd. Good afternoon or good morning. This is the thing, you can't really advance health equity unless we understand the context of public health. Public health allows us to move beyond what just happens in the health care system in the hospital, but really to fully understand the context of all of these other conditions and factors that impact our health, that are in our environment, that are our housing, our income, our jobs, our education. With this 10 essential public health services, this year is the 25th anniversary of launching them. They were actually launched in the 1990s, under the Clinton administration when they were working to do health reform and really trying to get very clear about what is the public health system about.

It was considered disorganized at that time, and they wanted to have better organization and clarity around it. The 10 essential public health services were created and put in place by a whole group of folks across the country, and that's really the foundation of public health in this system. It is really one of the best organized systems because of this foundation of the 10 essential services. Public health departments utilize it. It's used by accreditation bodies for public health degrees, but also for health departments themselves. It's just a really concrete way and the bread and butter of what public health is. Now—

Unger: Can I ask you a question?

Dr. Maybank: Sure. 

Unger: When this was originally developed, was health equity the issue that it is today? Was it built into the framework or not?

Dr. Maybank: Health equity as a field had not really quite—it started to emerge, 1985, '86 was the time when, at the federal level, Margaret Heckler, who was Secretary of Health at that time, actually published one of the first governmental reports that showed this disparity in health between Blacks and Whites and launched the Office of Minority Health, but it really wasn't quite yet at that time, in which you started to see health equity really be explicit, this elimination of health disparities, it was starting to mount, but it wasn't fully built into or embedded into the 10 essential health services at that time in a very explicit way.

To that question, now, 25 years later, with all the feedback that has happened across the country in revising these services, it is now very clear and the ask and the demand was we have to center health equity. We have to center equity, not only as an outstanding principle and moral and foundation of these services, but it has to be embedded throughout the entire services. All of them. There has to be some context and shaping of health equity through it.

That's really one of the key changes as we move forward and so, we have this launch that is happening at 3:00 PM Eastern Standard Time and there will be a link on our site and I think in our social media pages of AMA to register, and we highly encourage people to register for this launch. We as AMA have been at the table, so it's been very exciting and I think exciting to have—not only just exciting, important to have a health care entity at the table of public health, to say that both systems are critical.

Unger: That is so important. How does someone go about updating a framework like this?

Dr. Maybank: Yeah. Exactly. It's been the collaboration and coordination of—there was the Public Health National Center for Innovation, the Public Health Advisory Board, and they pulled together a national task force that has APHA, the American Association of Public Health. It has the Trust for Public Health of America, it had TIMES UP Healthcare at the table. It had NACCHO, who oversees the city and county health officials and then the state and county health officials also at the table ask though and then us as AMA. We were at the table, they did a great job at feeling the initial 10 essential services to the public, who provided feedback and then we revised them a little bit further and then they were sent back out for further public comment and then further refined.

I think it was a very good equitable, in a sense, democratic process of how we've moved forward to really revise these services. I think we're all excited for them to come forward. I think during this time of COVID, I think it's even more critical to really understand this context of not just only public health as a framework, but public health as an infrastructure and a system and how critical it is that it has to be funded. We know it's an underfunded entity within the context of our whole health system, but it's such an important one and a foundational one to all aspects of health within this country.

Unger: Yes. That level of importance has really been brought to bear during the pandemic. I know you've been a big part about providing the equity lens, you and your colleagues at the Center for Health Equity, so thank you for your efforts on that important initiative. I think the equity issue has been also made more visible by the recent passing of superstar Chadwick Bozeman. How does his death reflect an equity issue and how does it connect to some of the disparities that we've seen with COVID-19?

Dr. Maybank: Yeah. Chadwick Bozeman's death I think has hit many of us hard for several reasons. Definitely highlights that, I think, as you said, the inequities, right. He's 43 years old and passed away from colon cancer. The recommendation had been for colonoscopies around age 50. Even in somebody who is perceived to be in good health, good condition, from what all that we hear, was not at the point or readiness to have screening for colon cancer, which is very good if you get screening for colon cancer very early, and it catches cancer or changes in the cell or polyps early, you have a good chance of survival and cure rates, but when you catch it at stage three of which he was, then the circumstances tend to be a little bit dire.

At 43, when you're below the age of screening, it kind of signals, so what does that mean overall? We already know in this country that Blacks are experiencing higher rates of colon cancer and higher death rates of colon cancer and that all leads back to some of the contexts that I talk about often, that the roots of why these inequities exist. The inability to have equitable access to health services, quality of health services, who's told to screen, how people follow up for screening and the reasons why people may not follow up for screening.

Oftentimes it's still in that rubric and umbrella of our country's history of systemic racism and exclusion. We have to be able to name and claim that, but it's important to understand that as people of color, that these rates are higher and during a time of COVID, of which were already concerned and dealing with a major pandemic, a major disease that also affects Black and Brown communities at higher rates, one we're more likely to be exposed to it because of inequities and the jobs that we may have as essential workers, overcrowded housing, all of that and also higher deaths, for all the reasons that I mentioned just now for colon cancer.

You're dealing with COVID and then you're dealing with inequities of existing diseases, that we've had an inequities over time, and it just compounds and comes together. I think it's like this crisis, this tremendous crisis of COVID and comorbidity, and we have to really dig into that and understand it better. We're seeing more and more research and evidence come forward.

JAMA is now publishing articles about the impact of COVID again on long-term health impacts, as it relates to heart inflammation or myocarditis, they call it, at the long-term. Again, not only now dealing with COVID, dealing with the preexisting health conditions that we mentioned, the preexisting social conditions that people live in and then now these possible long-term effects that also create impacts of health for communities of color.

I feel like it's really hard to turn away from inequity and injustice as it relates to health, and it's right in our faces, and I think if there's any time that we as a health care and a public health care community need to come together and figure out what are our strategies at an organizational level, institutional level that we need to employ and embed in our institutions in order to dismantle racism, but also close these gaps of inequity.

Unger: Yeah. These rate differentials that we're seeing, that we've seen with COVID and now for colorectal cancer, Black people are 40% more likely to die from colorectal cancer. That's that is a stunning differential. Do you have any sense of what is driving that at the foundation?

Dr. Maybank: Part of it is some of the things that I mentioned before in terms of the health care system and what people have access to the quality of it. Screening is one part. Our screening rates need to go up as Black communities, but even when our screening rates are still up and are good, we still are still dying at higher rates. Oftentimes it has to do with other issues related to follow-up, post-screening, what happens then? What happens in the communication between the doctor and the patient? Is that good communication? Is the patient trusting of the hospital system? Can they afford certain aspects of the treatment and recommendations that are going forward? There are a myriad of downstream barriers that are not dissimilar or different than all the reasons why some of the other inequities exist as well.

Unger: You mentioned trust. I think it's a fact that Black men are especially likely to refuse a colonoscopy. There's a lot of mistrust with the medical community. Can you talk a little bit more about how that is affecting the Black community?

Dr. Maybank: Right. I would say, yes, there is mistrust from the Black community, but I think to frame it differently, there's a lack of trustworthiness on the part of health care institutions, historically. We have experiences and most people like to point to Tuskegee as the event, but the reality is that people know about Tuskegee, but people know about their own experiences of their own families and their own interactions that have potentially been problematic with the health care system. Either where they feel like they're ignored or they're not listened to, they try to seek advice and they're not sure if they should be trusting of it. It doesn't just happen in the immediate sense, this is long-term generational kind of experience and trauma and memory that people have about the health care system.

While doctors are still themselves very trusted entities, the systems themselves of which we sit in as physicians are not as well trusted because there are many different parts of which people interact with as it relates to the health care system. We say this a lot, mistrust, mistrust, mistrust, but I feel it's really a challenge for health care systems to figure out fully, what do they do to overcome that? How do they become more present in communities in meaningful ways, I think is really important before anything happens to that patient before crisis like COVID. What are the relationships that you're building up as a system so that folks can know that your doors are open to them, that you're welcome into that space? There are people that look like you, that's part of the challenge too. The lack of diversity of the workforce. All of these things come together at this complicated picture of why there is mistrust in our communities. I think the important thing is that recognize it, yes, but then what are we going to do about and not just say that it exists?

Unger: Well, that's a good segue into my next question. A lot of these health equity issues, they're kind of built into medicine. We see one in development right now, literally, regarding vaccines. Talk about the latest news in that area, and what we're doing about it.

Dr. Maybank: Sure. Clinical trials, vaccine trials, another area that inequities absolutely exists. It's only about 3% to 6% of people of color that actually participate in clinical trials, and there are many reasons why that is. One, the mistrust issue and the experimentation and the history of that and the knowledge of that. Not only in far past, but more recent past. The reality is that a lot of primary private practices, they aren't spaces where clinical trials are typically promoted. Oftentimes those are really at the tertiary care centers and so they're not often getting to marginalized communities and many people actually to promote those trials and have those conversations through their trusted primary care providers.

Then also a challenge again, because of the lack of diversity of the field of science in this way, the way in which these programs are delivered oftentimes are not in a culturally relevant manner. Sometimes they're not even in different languages, the promotion of them. There are several barriers of why there's this lagging of participation of people of color in clinical trials.

When we look at now this COVID vaccine trials that are happening, we are lagging in participation as it relates to diversity. There's definitely been a push by the federal government, by the National Institutes of Health to really work on the diversity, but the reality, we haven't met it. When you look at, last month Moderna and Pfizer, companies that are really leading in this vaccine creation, they enrolled half of their people, but there was still only a very small percent that were of color or Black and Latinx more specifically. Only about one fifth of the participants, when you really want more of about one third to be from Black and Latinx communities.

The concern about that clearly is with anything, is there going to be good representation? How are we really going to understand how these vaccines work in other communities other than White communities? The challenge with that statement also sometimes is we understand that race is a social construct, right? Somebody could say, well, if race is a social construct, then why does it matter?

What we understand about how race is a social construct, the system of racism around it has affected people and how they're able to handle whether it's medicines, vaccines, treatment, how they're able to deal and interact with the system does matter. We need to understand how vaccines happen across communities or if they're safe and effective, rather, across communities. That's what's really important for us to get and understand, not just one community.

Unger: One other area where there are clear inequities is around blood pressure and heart disease. Can you talk a little bit about what the AMA is doing to address inequity there?

Dr. Maybank: Prior to even COVID coming into our space, we were about to embark on a campaign on heart health. AMA has been doing a lot on hypertension and high blood pressure control, with a focus on equity and racial equity, understanding the disproportionate impact among Black communities. With the MAP program that exists, that is helping to support health care providers take more accurate blood pressure measurements within their own spaces, but also help support patients take more accurate blood pressure measurements within the context of their home. It's like, so how are we going to reach the patients in a meaningful way in this country and in a large way and at scale? Early on and also some folks who were already here at the AMA thought, well, why don't we partner with a trusted brand and a trusted entity that has a large reach and engagement with Black communities?

We initially thought what would be great was to engage with Essence, the Essence brand magazine, which is predominantly, initially focused towards women, but women in Black communities are very central to their communities in terms of their families and the support that they provide one another as women also is really a central tenant of the culture. We figured that this would be a great vehicle to engage and get out this message and then COVID comes around and we had to switch up a little bit and really question should we really go forward with this or not because many of our mechanisms of engagement were going to be in person.

Then when we heard the data, that many people were not seeking care and were still staying home who had, whether it was heart disease or they were feeling chest pain, as an example, and they weren't going to the emergency room, there still needed to be information out there about taking care of your heart health during this COVID time and how to do that and to do it in terms of a management perspective and also prevention perspective.

There's an aspect of it where we're talking about and encouraging conversations with your health care provider. Making sure you know your numbers and you're documenting that, those numbers. If you can get access to a self-monitoring blood pressure cuff and we've done a lot of work on validating those here at AMA, but getting that and having that in your home and taking your blood pressure and learning how to take it. The site on AMA, this partnership that we have with AMA and Essence and rather the website on Essence, you're able to go in and view videos and how to take your blood pressure accurately. You're able to view information on how to have the conversations with your physician and then to take it to the next level. Oftentimes, especially in this COVID time, which became very isolating for many people and still is across the country because we're not supposed to— we're social distancing, all kinds of things. It teaches you how to engage virtually. It encourages you to engage virtually with your friends and with your families for wellness and creating a wellness plan around all of that.

We're working on building that out. We're working with many partners, the National Medical Association, the AMA Foundation, the American Heart Association and the Minority Health Institute, to really deliver and amplify this opportunity and bringing on partners constantly as the year goes along.

Unger: Well, thank you so much, Dr. Maybank for sharing your perspectives today and for all the work that you and the Center for Health Equity are doing. That's it for today's COVID-19 update. We'll be back tomorrow with another segment. For updated health equity information and other resources on COVID-19, visit ama-assn.org/covid-19. Thanks for joining us today and please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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