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July 5, 2024

Health Disparities

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Health Chatter
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Stan, Clarence, and Barry chat with Dr. Miguel Ruiz about health disparities.

Dr. Miguel Ruiz is an internal medicine and palliative care specialist who has practiced in Minnesota for over twenty-five years. After working as an internist at the West Side Community Health Services/La Clinica serving Latinx and other diverse communities, he transitioned his practice to Regions Hospital where he worked as a hospital medicine physician and a palliative care specialist. Dr. Ruiz is also an assistant professor in the Department of Medicine at the University of Minnesota and is actively involved in the training of students, residents, and fellows. Presently, he also serves as the HealthPartners Hospice’s medical director and is the lead physician for its Palliative Care Community-based program. Dr. Ruiz has been involved in several diversity, equity, and inclusion projects. He is currently a co-sponsor of the Regions’ Health Equity Committee and has a special interest in the areas of cross-cultural medicine and cultural humility.

Listen along as Dr. Ruiz shares his knowledge on health disparities.

Join the conversation at healthchatterpodcast.com

Brought to you in support of Hue-MAN, who is Creating Healthy Communities through Innovative Partnerships.

More about their work can be found at http://huemanpartnership.org/

Research

  • What are health disparities? 
      • Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations (CDC)
      • A particular type of health difference that is linked with social, economic, and/or environmental disadvantage (Healthy People 2030)
      • Health disparities result from multiple factors including poverty, environmental threats, lack of access to health care, individual/behavioral factors, and educational inequalities 
      • Health disparities are inequitable and directly related to the historical and current unequal distribution of social, political, economic, and environmental resources 
  • Examples of health disparities 
      • Individuals with less education are more likely to experience a number of health risks such as obesity, substance use, and intentional/unintentional injury compared to those with more education
        • Higher levels of education are associated with a longer life and increased likelihood of obtaining health information and services to make health decisions 
      • Racial and ethnic minorities in the United States have higher rates of chronic disease and premature death compared to their white counterparts 
  • What is the scope of health disparities in the United States? In Minnesota?
      • United States 
        • As of 2021, people of color and other marginalized groups continue to be without health insurance compared to their white counterparts 
        • People living in rural areas have a more difficult time accessing care compared to those living in urban areas 
        • COVD-19 took a disproportionate toll on the health and wellbeing of people of color and other marginalized groups
      • Minnesota
        • Black and Trans Minnesotans reported highest rates of unfair treatment by healthcare providers (see graph below)
        • MN has some of the worst health disparities in the country because of significant inequalities in areas like income, education, and home ownership (MDH) 
  • Why should we address health disparities?
      • Improves the nation’s overall health and economic prosperity
      • Important to address as the population becomes more diverse and income inequality continues to grow 
        • Projected that POC are to make up over 50% of US population by 2050 
      • When people have equitable experience to quality healthcare it enhances early detection, prevention, and management of chronic diseases, resulting in reduced health disparities (mn.gov)
  • How do we address health disparities?
    • Social determinants of health (non-medical factors that influence health outcomes)
      • Priority area within Healthy People 2030
      • Addressing health disparities gets us closer to achieving health equity 
    • Healthy People 2030
      • Goals include eliminating health disparities, achieving health equity, and attaining health literacy to improve the health and wellbeing of all”
    • Health and Human Services (HHS) Equity Action Plan
      • Advancing equity by improving care for children, promoting accessibility, improving mental health outcomes for minority communities, prioritizing behavioral health of underserved populations, and increasing clinical research to support innovation 
    • Centers for Medicare and Medicaid Services (CMS) Framework
      • Priorities include expanding data reporting/collection/analysis, assessing causes of disparities, capacity-building of orgs to reduce disparities, advancing health literacy, and increasing accessibility 
    • MN Health Access Survey 2011-2021
      • Measurable goal for 2027 → reduce percentage of Black and Trans Minnesotans reporting unfair treatment by healthcare providers by 50%
    • Advancing Health Equity in Minnesota: Report to the Legislature, 2014
      • Assesses disparities and recommends best practices, policies, and other strategies to promote health equity for all Minnesotans 

Sources

Transcript

Hello, everybody. Welcome to Health Chatter. Today's show is on health disparities, and we have Dr. Miguel Ruiz with us. We'll talk to him in just a second and introduce him. We have a great crew, as if any of you in our listening audience have heard some of our great shows. We always like to recognize our staff. Today we have Sheridan Nygard is doing our recording for us. Thank you, Sheridan. Sheridan also does background research for us and in our marketing. Maddy Levine-Wolfe, Erin Collins, and Deondra Howard also do some good background research for Clarence and I. So we sound kind of smart when we're talking with our illustrious guests. And also Matthew Campbell is our production manager. he makes sure that these shows get out to you, the listening to audience in really crisp form. 
So thank you to all of you uh Dr. Barry Baines is our medical advisor. Barry, thank you. Clarence Jones is my co-host for this show uh having a lot of fun we we catch up with one another uh often actually over a good cup of coffee to make sure that we're all in sync. And we're still having fun and a good time doing these shows. And when it stops being fun, we stop doing Health Chatter. But so far, it's been a real pleasurable ride. So thank you to everybody. Thanks to our sponsor, which is Human Partnership, a great community health organization. Check them out at human, H-U-E-M-A-N, partnership.org. And also, check us out on our website. We put up all our background research for our shows so you can read them. 
Our shows are transcribed so you can read them or listen to them at your pleasure. And also feel free to provide feedback about our shows on our website. If you have questions, put them on the website. Clarence and I will get back to you as best as we possibly can. So thanks to you, the listening audience, as well. Uh, health disparities, which is actually it to me it's it's like okay what's new, but we'll get to that in, in, in a minute for sure. We have a wonderful guest with us. Dr. Miguel Ruiz is an internal medicine and palliative care specialist who's been in, in, in the state of Minnesota for 25 years. Nice, nice, uh, chunk of time after working as an internist 
at one of our community health clinics. He now practices at Regions Hospitals where he works as hospice medicine physician and a palliative care specialist, an assistant professor in the Department of Medicine at the University of Minnesota. And he is currently a co-sponsor of the Regions Health Equity Committee and has a special, special interest in the subject that we're talking about today. So many, many thanks for being with us. This is a complicated subject, and I know that you have some great insights. So thank you for being with us, Miguel. I really appreciate it. Clarence. Good morning, everybody. I am excited to have Miguel here to talk about this topic because I think it is one of the, as Stan said, this is one of the most interesting topics to have in this country, but also especially in Minnesota. 
So I'm going to leave it there and let Stan start talking. But I have some really probing questions to ask in your opinions. And this is health chatter. So we are not necessarily politically correct. We just want to talk. Okay. All right, Stan, I'm turning it back to you. Here we go. So, all right. So Clarence and I, and actually all four of us, we've been in the healthcare field a long time. What really is striking to me is, have we had disparities? And if so, why is there so much attention to them now? Or we're hearing about them, at least for sure I am, hearing about them much more today than we did, say, 15, 20 years ago. And Even then, we had them. 
We had disparities. So what's driving this discussion now? All right. Good. Great question. Thank you very much for having me here with you. And I am glad this is going to be a conversation because, as you know, some of these deep questions don't have a clear-cut answer or simple answer. Absolutely. These are very complex topics. You know, I'm not sure what has brought this to the forefront now in the last few years. You're right. Disparities have always existed. From the very beginnings of medicine and history, there's been discrimination, disparities, and the forces behind them that have existed. And that is actually known and the case even in the beginnings of medicine. we have an increased awareness of how our early fathers in the medical science really, unfortunately, use very racist approaches to care, from the mistreatment of enslaved individuals to the use of these for experimentation, to really misconceptions, even in our most prestigious journals. 
For example, the New England Journal of Medicine Earlier this year and in the last couple of years, I've had some series of articles on racism in medicine and healthcare disparities in medicine. And they go to a historical review of such. So this is not a new topic. Healthcare disparities and health disparities have existed from the beginning. I think many factors go into why now to your question. Yeah. I think one of the factors is that we have had a greater capacity to measure. We have been much more focused on outcomes. And because of the technological progress and developments, we are able to extract data much more easily than we used to in the older days, when a lot of the research was much more manual. 
And now, with powerful computing systems, we're able to extract data from electronic health records, which we didn't have before. in a much easier way. Therefore, having access to these metrics very quickly and in a very efficient way. Thus, in terms of the technological, then there is obviously the whole social moment that we are living. And as you can see, obviously, the history of our country and the history of humanity has had highs and lows and peaks of awareness of the disparities, racial and otherwise. And as you know, the last four or five years have been very active years for unfortunate reasons on those issues of the injustices of our society. And obviously with healthcare injustices are at the very core of injustice in general because of the consequences of such. 
So I think those are two things that come to mind. I know there are probably many others, but there have been scientists and researchers that have been looking into this topic for many years, not just the last few years. Clarence? Yeah, I want to ask this question. You know, America is often, you know, touted as the leading country in a lot of different kinds of things, and I think that we know that that's not necessarily true in a lot of areas. Minnesota is often touted as a one of the healthiest states in the union. But yet, when it comes to health disparities, it isn't. And what do you think is going on? I mean, how can we be healthy for one group of people, but not healthy for the rest of the community? 
What do you think is happening? Great, great question as well. I think one of the contributors to a greater gap for Minnesota is that the outcomes for some individuals are very excellent. So when you have a gap, the gap is differential in between a health status or health outcome in between two different or three or four different groups. So when one group has excellent outcomes, that makes the gap bigger, even when the outcome for that more disadvantaged group are not worse than the outcome for that such a group in other parts of the country. So I think that's one of the contributors. And of course, when we are going to talk about closing the gap and about eliminating or decreasing disparities, what we want to do is to bring the lower group up to the standards and the outcomes of the upper or the more advantage group, not lowering that higher group into the lower. 
And just a fact that I think hopefully will lead us to also talking into what we call social determinants of health, is the fact that, for example, Latino high schoolers have the lowest graduation rate in the country. That is, Latino students in Minnesota have the lowest graduating rate from high school in the U.S. So we have these pockets of inequity, to call it somehow, in certain groups for reasons that are, I don't think, completely understood. but are a painful reality. How can we have such a good performance in so many metrics and indexes, as you refer to, Clarence? And yet we have these very painful realities of specific groups being really very behind compared with even the rest of the country. One of the things I want to say is that in this particular topic, I don't point fingers at just one 
one one group of people. I think that there's a a lot of uh of growth for a lot of different people, whether it's whether it's in providing access or whether it's providing information uh about this topic. And so uh i i want to say that up front is that, you know it sometimes in this particular topic, people like to say, well, it's their fault or our fault or whatever else. But this is a conversation that i think that we have to have to be really honest about. that there are some real gaps around health disparities that we as a community have to address that will benefit us by addressing them. So that was just my comment, because I can get very pointed at times. 
But I'm not blaming folk. I'm just saying, hey, we have some realities that we have to talk about. So Stan, I'm sorry. Go ahead. Yeah. So Miguel, you brought up the, actually, you brought up a point that I was thinking, why is it that it's come to the forefront? And you eloquently stated the idea that we have better ways to measure. And that's good. And so I think we're at this point. We're kind of at this inflection point, it seems to me, that, OK, we've had them. We're able to analyze them. And then the next question is, What the heck do we do about it? And the next question is, how do we know if we're making a difference? How do we know if we're getting to where we want to be? 
So just a reflection on all of that from your perspective. Yeah, no, that's great. I think the question is no longer, do we have healthcare disparities? We have. The answer is very clear. And you know, it's very clear to most people to most people, to most stakeholders. There was a time not that distant in the past where some people were very skeptical about, yeah, about the disparities because hospitals and medical groups were providing good care to everybody who comes through our doors. And there was that perception of we are doing the best we can with everybody. We don't, quote, see color and so forth. And really showing this data has been very important to leaders in health care to say, actually, yes, you are doing your best, you think, but you do have health care disparities in your system. 
And these are the numbers. So now the question is, what are we going to do about it? Because we do have those disparities. And perhaps we make a parenthesis, because I think the answer to that question really requires that we have clear concepts about some of the terms that we use here interchangeably. One of them is, what is health disparity? And basically, health disparity is a difference in health, in health status, in outcomes that is in between groups, that is closely linked to social, economic, environmental, and so forth disadvantage. Okay? So it's about health outcomes are different in between two groups. Then we have healthcare disparities, which are... Basically, they are the difference in accessing care, in the quality of the care, in the use of the care, in having insurance or no insurance. 
Okay? So, because I think when we talk about what can we do about the disparities, we need to know what the problem is. There are health disparities. There are now also healthcare disparities. That is the way we provide medical care for patients is healthcare. It has some inbuilt disparities. And then what is my area of impact? I think each one of us has to ask the question, what can I do? Because what is clear is that some of these disadvantages, social, economical, environmental disadvantages, these are huge policy, political, and societal issues that one can feel very important to do anything about. And then you can say, well, there's nothing I can do to change this huge monster of injustice. And basically you give up and just do nothing. 
But the question is, what can I do where I am, like you with your podcast today, to raise awareness, to bring the points, to make a call and appeal for change? And I think I can perhaps speak a little more about what can we do from my position in terms of being within healthcare about some of those questions. health care disparities. But just to throw a couple of numbers, if you give me 30 more seconds here. Health outcomes, health disparities. One of them is, for example, survival or life expectancy. I mean, what other health outcome more final and more direct that how long a human being lives? So life expectancy, a clear gap in between black and white, people of color and white. 
At the level of the country, you look at a map of the U.S., very stark differences in between different regions of the country about a baby that is born, how long it's going to be expected to live, based on where you live, based on the color of your skin. In the Twin Cities, for example, just to bring it local, health care, I mean, life expectancy difference in between Let's say a few blocks west from the hospital where I work, in the Frogtown area of St. Paul, just north of I-94, you compare life expectancy of the community living there with the life expectancy of individuals living three and a half miles going west just before you cross the river, right? In that neighborhood, also north of I-94, just by the University of Minnesota, 13-year life expectancy difference. 
Wow. In the very core of our cities. So why? Why that stark difference? You know, many of our inner cities in the U.S. have life expectancies in certain neighborhoods, similar to life expectancies in Haiti or somewhere else. countries, limited resources countries. And that's a reality in the very midst of our society in our country. So why? Well, because if we are talking about what are we going to do about it, we need to figure out what are the causes of disparities? What causes disparity? What causes health? And something that I think many people are not aware, because we believe health is all about healthcare, many people are not aware that actually the medical care we physicians provide, our care system providing medical care, accounts for 15 to 20% of the health of a community. 
Again, the care with authors within, we are making the big difference here, but we need to be humbled by the fact that what we do, basically, is creating the health of the community for no more than 15 to 20% of the health of that community. Yeah. So the question is, what else are the determinants of the health of a community? And that's back to our social determinants of health. So it is those economic and social factors, is the environmental, the neighborhood, the safety, the ability to have... clean environment with less pollution, the ability to have parks where people can exercise safely, the health behaviors of these communities and individuals, those are the main contributors to the health of a community. Yeah, Poy, you really hit the nail on the head. 
The problem is, how we go forward in in previous in actually quite a few of our shows, we've had a focus, uh, or we've asked our guests, um, questions related to prevention, acute treatment, and disease management. Obviously, Miguel, you're saying that that that 20 that the the health care professionals are helping with are basically in the acute treatment and disease management. And prevention is a hard one. It really is. It's one thing to know what you want to prevent. It's another on exactly how it is that we can go about doing it and maintain it over time. It's not like a one-shot type of thing. Go ahead, Barry. Okay. So, Miguel, I have just a couple of paths that I just want to put out there. 
In my 35 years of practicing as a family physician, I became very aware that there were waves of immigration into Minnesota in particular. I'm thinking we had the Hmong population in the 70s, Somali, Ethiopian, Karen. Latino populations. And so it sounds like from a disparities perspective, it's always a moving target when you get a new group of people into the community who are not necessarily aware of how to access care, language issues, education. Obviously, the pie chart that I hope our listeners will go to that pie chart which will be posted because I think there's a sense that, oh, yeah, it's the clinical care piece that one of the threads that I see is this education piece that you alluded to in talking about the Latino population and graduating high school. 
And a lot of determinants like health behaviors, if you're not educated about them, it's hard to change those kind of things. And then from a community perspective, a more educated community might be able to have a bit more leverage at least in terms of some of the social and economic factors. And I will get to a question or a thing for more conversation of how that pie chart breaks things up to see where the big levers are and It seems like the bigger the piece of that pie, the more complicated that it is to get into that. But to circle back, I was just wondering what you have seen regarding influx of groups from other countries that have different customs, different cultures. And then as a Caucasian physician, my cultural competency early on was very low. 
And I was very grateful to be able to have this initiative to really understand what you have to do to be culturally competent. And it really changes the face of how you interact with patients. Understanding that a Hmong patient can relate better with a Hmong physician. A Latino patient can have a better relationship potentially with the Latino physician. And so that's another piece is that minority groups tend to be underrepresented as well within the medical community. So I'll just kind of, you know, those are my my thinkings about this. Just wonder if you could maybe touch on some of those or share some of your perspectives. Be very interested. Yeah. Thank you, Barry. I think you bring a very important point. And obviously coming from your own experience, a realization that, boy, this is a challenging time. 
a challenging area to tackle, and yet is actionable. There are things that one can do that are specific and that make a difference. I think COVID-19, I think this pandemic has really given us another view of the impact of this social... It was a wake-up call. Totally. I mean, the impact of the socioeconomic... and educational level and so forth, we saw clearly that Latino black were not only affected more by infected more than whites, but also got sicker and have higher mortality. So a lot of has gone into why, why? And I remember reading a study from Harvard, looking at their population in Massachusetts in which they realized clearly identified for the Hispanic Latino was the fact that they were living in overcrowded houses with multi-generational members of the family, meaning children that were going to school and going out with elderly parents who were living under the same roof and without little ability to do more isolation when one was infected, with less health insurance to go and be tested, with perhaps less means to drive to a testing site. 
somebody who may have access to a car. And also with some of those middle-aged individuals in that same house working in a meat processing plant where high noise requiring to shout and scream to communicate also contributed to higher transmission. And then you look at the black community living in high-rise apartments using more public transportation. And they identified all these totally socioeconomic factors that made a difference into, and obviously with higher rates of underlying comorbidities, diabetes, and pulmonary diseases that place individuals at higher risk for complications from COVID. So just to give you yet one more, in case we didn't have enough, one more view and taste of how these factors do impact these communities who are being marginalized and who are at a disadvantage. 
So I think, glad that you mentioned, Barry, the issue of cultural competence because, and again, one of the factors for COVID was new arrivals. You talk about the new waves of people arriving. For the Hispanic Latino newcomers have not only no connections in the community to know where to seek care, but also no health insurance. The Hispanic Latino is the most uninsured community in our country, therefore delaying care. I had so many cases during the COVID-19 coming to the hospital. with an advanced case of COVID, with complications, having to be intubated in the medicine department because they were not able to be tested, because they didn't have the health literacy to be able to understand where the risk factors of the symptoms were. 
But what can we do? And you mentioned the word cultural competence. And I think I have a bit of a special feel about that concept because in my mind, I prefer to use the term cultural humility. And just to make the point very, very, very quickly, the one aspect that I don't like about the term cultural competence is that the word competence assumes some degree of mastery, of expertise, of arrival. We got it. We are now incompetent. Where I think it's very important to realize from the get-go that we will never be able to really understand a different culture and community to ours to the degree that we are competent. Of course, absolutely, one has to study, learn, talk to the community, really get as much knowledge and understanding of that group of people. 
But I think with the humble approach of always going with the desire to know more, to have a healthy curiosity, seeking to understand before we try to be understood by them. And I think that's something that we as healthcare providers need to have very clear. We need to really put our... ideas and our best ways in the back burner and become students of our patients and declare, I don't know, I need to know, I want to know, help me know what matters most to you, what's most important to you. How do you think, why do you think you are sick? What do you think is causing this problem? Really trying to get into the narrative that they are living in so that you can from there start to develop some approaches to helping them. 
And of course, also to always be conscious about the healthcare, the power differentials. The fact that many individuals who maybe may have a low English proficiency and thinking about the community and more familiar with the Hispanic Latino community, there is this huge differential between providers and patients that we need to really be very creative about thinking, how do I equalize this this encounter in a way that I'm going to be able to connect with this patient so that I can understand how to better help them as opposed to just trying to think that I am the one who knows how things should be done. Anyway, sorry to go a bit on a tangent. Just one thing. I really like that term of cultural humility rather than cultural competency because I never felt competent. 
Uh, I had a lot of humility. I like to learn things so right so it was always interesting to me to learn those new things. But I think having that that mindset you can never know enough. And it was always what i didn't know. And it was always there. There was so much, so much more. I didn't know than what i know so maybe if i became, you know again less less incompetent but that you need humility for that as well i really appreciate hearing it, uh, put in that way was very, very helpful for me. Thanks. Yeah, I love this thread of conversation. Thank you, Barry. Barry, thank you. And Miguel, thank you. Because as you know, I started off my conversation, my initial remark by saying, I'm not pointing fingers. 
It's very important not to point fingers in this particular conversation. But I do hear this thing about cultural competency and people saying, well, you know, One group of people can work well with their group of people and those kinds of things. But the reality is that we don't necessarily have those medical people in place like that. So what are we looking for? We're looking for accurate and appropriate information. We're looking for authenticity. And so many times people will say, well, you would work better with a doctor that looks like you. That may or may not be true. What we're looking for in this particular case in order to address health disparities is an honest conversation. You know, an authentic doctor, somebody that comes in and says, look, you know, I don't understand those things, but I do know that I want to show you that I care for you. 
And I think that that's one of the places where we miss this is that by saying that, well, you would be better served by someone from your own group. it allows you not to serve most appropriately. So that's why I say this is a conversation that we have to have because some people, you're not comfortable with serving certain kind of people, but I think you can say that. Yeah. Yes. If I may say something about that, you're right. And yes, we don't have enough BIPOC providers to care for our BIPOC communities. And unfortunately, recent report in the New England Journal of Medicine, again, in the last 40 years, the number of black doctors, male black doctors in the US, not only has not increased at all, but has gone down slightly. 
Yeah. 40 years. So studies, I just read a recent study which showed that if black patients were cared for by black doctors, they estimate... the disparity in outcomes, the health of cardiovascular outcomes, the disparity will decrease by 19%, by 20%. The reality is we don't have enough BIPOC providers, but the reality is we need to do... That's one of the many things we need to do is we need to advocate for more physicians of color coming into medical school, especially from those communities that are... the most underrepresented, the black community being one of them. So that is something at the level of policy and at the level of advocacy that we need to advocate for because most people prefer to be cared for by a provider who looks like them, who may have a better understanding of their culture or who may speak their language. 
And it's trust. It's an issue of trust as well. Yeah, it's an issue of trust. You know, there is something there about, you know, I see you, I think you can understand me because I see you are... from a similar background. But you are right, Clarence, that that is not the only solution because that's going to be an impossible target. We need to work on it, but what do we do in the meantime until hopefully one day we get there where we have our healthcare providers representing the same diversity of the community they serve. But you know, today, human resources and medical groups and clinics and hospitals At least my hospital is tracking very closely what is the racial distribution of our nurses, of our, you know, CNAs, of our physicians, of our APPs. 
We are tracking that. And we have established clear benchmarks that we want to accomplish because we want to move the needle on this area. Because it's an actionable area that we can do something about that we think is going to decrease disparities and improve it. the health of our community. But yes, you're right. We need to really get to the point of trust and care, even when we have racial and linguistic incongruity or differences. And that's the importance of many, I mean, we could talk forever about what things we could do. I can tell you what we can do, what we are doing in my hospital and in my medical group. But I mean, absolutely, you need to use medically trained interpreters when you are seeing a patient. 
is not able to speak English. I will say, when I'm not able to speak Somali, I need to get a Somali interpreter to help me care for my patient because I don't speak Somali. It's not that the patient doesn't speak English, it's that I don't speak Somali. I mean, we have to really start thinking, changing our way of thinking and removing the blame from the patient. and put it on us to be able to see what do I need to do to provide excellent care for this patient. I think those are the ways of thinking that will really increase the trust and will send the message that we do care for our patients. So Miguel, I've got a couple of thoughts and then Sheridan, I'll get to you just in a sec. 
are we dealing today with more of diseases of our time? In other words, you know, if you think about, you know, around, you know, the early 1900s, we were dealing with a lot of infectious diseases. Okay. So today, okay. Where at least hopefully people get properly vaccinated, which is a whole other subject, but today we're dealing with, um, frankly, more complicated disease entities, the synergistic effect, you know, a combination of a variety of multiple variables that affect a particular disease. So do you think this synergistic effect is having an effect on addressing disparities? In other words, diseases are a little bit more complicated, you know, heart disease, you know, it's like, what's the cause of heart disease? Well, I could, you know, I could give you a laundry list of things that 
that caused that. So that's question one, dealing with diseases of our time. And then the other thing as it relates to disparities is this, the distinction between necessary care and elective care. So for instance, necessary surgery versus elective surgery. And are we seeing disparities there as well. So diseases of our time and necessary elective care. Let me see if I understand the connection here with, you're trying to connect this with the issue of disparities. Right. Yeah, obviously, as you very well point out, the cause of death of individuals have been The diseases that have been afflicting humanity and societies have changed based on the evolution of our lifestyle and our environment and the development of antibiotics and treatments that, you know, hopefully are benefiting most people. 
Although, again, you think about infections, you look at HIV, for example, clear disparity in terms of number of new cases of HIV in the US today, clear disparity. clearly higher among black individuals and Latino than white. Why is that? Again, back to the whole issue of education, living environments, stressors of life, and so forth. What we know is that people who are living, actually, before we talk about these A's, correct, the adverse childhood experiences, And now the researchers are talking about the pair of ACEs, which is the adverse childhood experiences, but also the adverse community environments, ACE, both of them. So even before birth, pregnant women who are suffering from continuous stress because of poverty, homelessness, you name it, drug use disorders, discrimination, poverty, poor quality of environment, and so forth, that in utero, in development human, is already been affected by higher levels of stress hormones, cortisol, adrenaline, norepinephrine, and so forth. 
That baby comes into the world into a situation of again, maybe homelessness, maybe incarceration of one of the parents, maybe emotional and sexual abuse of one of the parents and so forth. So this is leading to a situation in which by the teenage years, they're already having to cope with that added, they call it allostatic load of stress that has been affecting this individual that may have already caused some through epigenetic mechanisms, some disturbances in their nervous system. And that ultimately we know it leads to premature aging and to higher mortality and to shorter life expectancy. So it's there, it's in the society really. So how do the diseases of our days, to your question of diabetes, cardiovascular diseases, how are they impacted by these disparities? 
Greatly. because if really to be able to eat healthier food, you have to pay more. Or you have to have a car so you can buy the food in certain places. Or you are living with a food scarcity type of situation because you are in a food desert in a bigger city, in a larger city. Those issues are going to make you more prone to fast food, intermittent food that is going to make you more prone to poor control of diabetes or hypertension, and other diseases that lead to cardiovascular death. So that's why, for example, in our hospital today, we are starting to measure food safety on any patient who is discharged from the hospital. Social workers, case managers are assessing these patients' access to food before they leave the hospital. 
And guess what? And the safety of it. And the safety of it. And guess what? we are finding people who don't have food security here in St. Paul, okay? And guess what? Well, we have a partnership with Second Harvest or whatever nonprofit organization that can provide and we can do a follow-up and we can, how can we pretend that this patient is going to be worried about getting those medications that have been recommended following their heart attack or following their stroke or whatever else when they are most primarily worried about where they are going to be eating or how they're going to be feeding their children. I mean, we need to start building the house from the foundation, not from the roof. Exactly. 
And what we are doing sometimes with our traditional medical approach is trying to patch a sinking boat, and there's bigger holes than the medical problem. And I think basic needs need to be addressed, just to give you an example. Sheridan, thanks for being patient. Yeah, no problem. Also, I love the mention of Second Harvest Heartland. I used to work with them. Fabulous company. If you're ever experiencing food insecurity, consider checking out their resources. I also really appreciated your commentary on shifting our mindset in the health care field to shift blame off of the patients. I think that's a really important comment. We've also been discussing disparities mostly in terms of race and ethnicity. And obviously, we have work to be done in the racial and ethnic disparities. 
For example, the maternal mortality rates is much higher for black women in the US. And I'd like to push a conversation more towards intersectionality with the maternal mortality example. These patients are black and women. This is two groups that have disparities separate, but together they compound. And in our research from, I don't remember who did our research. I think it was Aaron or Maddie. Somebody did some lovely research. Maddie, thank you, Maddie. It's also pride month and our research showed that that black and or trans Minnesotans reported the highest rate of unfair treatment by health care providers. How do we address the compounding effects of disparities for individuals that exist in these intersections between race, ethnicity, gender, sexuality, sexual identity? Black and trans people are going to have a much different experience than white cisgendered. 
And how do we address these compounding effects? Thank you, Sheridan. This is so important. And you are absolutely right. And I think I should have clarified this from the get-go that it's not just about skin color. There are so many other categories of disparity. So thank you for bringing those up. Yeah, it is black, it's a woman, it's poor, it's with a family member in jail. I mean, the intersectionality there is just huge. And the result of systemic racism through racism centuries and generations and generations. So, complex. I think something that we, the data you present is based on uh back to the point i was making before about the cultural humility, seeking to understand. We need to listen to this community and really uh hear their perspective on the care they are receiving. 
So if lg btq individuals are perceiving poor care and discrimination, we need to say, yeah, I want to hear you because you're right, your perception. We cannot say, oh, we treat everybody the same, which is, you know, we have the same standard, the same protocol, the same algorithms. No, we don't. Because even when we do the same things, there is a human essence and there is still the issue of unconscious biases. and there is the issue of discrimination that happens and that is is there and it's it's proven and it's present. What do we do about it number one one one number one is we need to listen to these communities and and to be able to listen to them, we need to give them a place at the table. 
We need to reach out and say, tell us how are you being cared for? How are you perceiving your care is being? Tell us what do you see the problems are. Tell us how we can help you. Again, a humble approach to No, I do have developed these solutions to your problem and this is what we're going to do. No, I go to you and you tell me, how do you think you could be helped better? And doing something about what we hear. At the hospital, we have these equity rounds. We have them for a while where leadership, senior leadership, will go to rooms of patients who were in one of those categories, not just people of color, but a veteran or somebody who is, you know, different gender-oriented, 
or different sexual orientation or whatever else, and try to sit down with them and have a one-on-one conversation and take some notes. And apologize on the spot for whatever perception they already in that hospitalization were perceiving as being treated unequally. So I think that's the start. And then obviously at the level of policy, we need to advocate for those policies that are all about equity. And I just, let me remind all of you all of us that equity really is that everyone has the best chance to get the best outcomes possible or be as healthy as possible. Equity is not about we do give everybody the same treatment. Equity is about outcomes. It's how can we have everybody achieve the best health possible. 
Some people will need this to achieve that. Other people will need something very different to achieve that goal. And that's where we need to customize our care based on what we learn from these communities. So community engagement is very key. And then having those individuals being in patient board meetings and having individuals from those communities who are disadvantaged or have been made disadvantaged be at the table. But not only be at the table, talkerism, but be at the table and have a say at the table. Inclusivity. So true inclusivity, not just diversity, but diversity and inclusion, meaning giving these individuals the power to change policy, the power to lead. And that means that some of the folks need to step out of the table to give room for these individuals. 
And this applies to health care. This applies to politics. This applies to school boards. This applies to everywhere. That's, I think, the only way we're going to change the current environment. One of the things that I've gotten from your insights is we can learn from one another. And we need to really take the opportunity to listen carefully, hold hands together to make a difference. And if we all have that kind of mindset, I think, for instance, the goals for Healthy People 2030, we can start getting there. It's just the recognition, first and foremost, that we have the problems. Let's listen to one another and try to make differences and come up with ideas, creative ideas together. I think it's really good. Clarence. I tell you what, I know we're coming to the end of our show. 
Miguel and Barry and everyone, I thank you for this great conversation. It was very authentic. I like that. And Miguel, I'm going to take away a couple of your sayings, like building the house from the foundation versus a roof. I mean, it's like, hmm, that's good stuff. So thank you very much. And we definitely appreciate it. I definitely appreciate the authentic engagement. That, for me, is how we're going to move the needle around health care. We don't have to be afraid, you know, of saying what we really feel, you know, authentically and respectfully. And that, I think, is how we make it. So thank you for being on the show. Thank you so much for the conversation. I'm grateful. Thank you for your also. 
I've learned today quite a few things from you, too. So thank you so much. Barry, last comment. Well, I just want to thank Miguel for helping to increase my humility quotient, which I think will make me a lot, a lot smarter and a lot more compassionate and a lot more understanding. And, you know, it's one of those things that it's, it's good to be engaging in that, not to mention, again, the conversation here was, was just awesome. And again, I was so glad that I reached out to you to, that I thought of you to, to come on here. Cause that helps my standing with standing clearance that I get some good guests. This was just a, a wonderful conversation or a great, a great health chatter stand in clearance. 
And just again, thank you so much. And obviously we're scratching the surface on this. There's a lot more that we could do, but, But having this reflection, you need that step before you go to some action. But it just increases awareness. And you just start to see things through a different lens. And that's always very helpful. So thank you. Thank you. Thank you, Barry. So Miguel, I'm going to say this. This subject is huge. And I know that you are embedded in it professionally. So please, if indeed in the course of your work going forward, you come up with some aha moments where you think, God, this would be really good information to share on health chatter so that we can get this information or these ideas out more broadly. 
Absolutely. Feel free to contact us and we'll get you back on the show and we can talk about that. We reserve the right to call you back. And we say, hey, we need another shot of adrenaline from Miguel about this whole subject of disparities. And so many, many thanks. Your insights are golden. They really, really are. For our listening audience, we've got some great, great new shows coming up. Watch for us and listen to us, read about us, and continue to health chat away!

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