Native Health Initiative

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An introduction to Health Inequities-Anthony
Fleg, MS4anthony_fleg_at_med.unc.edu

• Brought to you by the UNC Chapters of the
  
• American Medical Student Association
• (AMSA) and Student National Medical
• Association (SNMA)

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Initial questions to consider

• What populations in this country experience
  health inequities?
• - race/ethnic African American, Latino,
  American Indian, segments of Asian population
• -geographic rural, inner city,
  reservations, entire southeast
• - sex LGTBQ population
• - other - homeless, jobless, uninsured,
  under-insured, non-U.S. citizens, poor children,
  poor elderly
• - etc.
• Are we angered by the long list? In our heart, in
  our gut, are we troubled by the fact that so many
  live with sub-optimal health and healthcare in
  the richest country on Earth?
• Are we willing to fit into such a system, or are
  we committed to change it, beginning with
  ourselves?

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Initial questions (cont.)

• Our simple question, whenever we see a difference
  in health/disease between two groups, should be
  Why?
• -for a small minority of differences, such
  as higher rates of breast cancer in women (vs.
  men) or higher rates of sickle cell anemia in AA
  (vs. Whites), the answer to Why is biological,
  and is not preventablethese are examples of
  differences or disparities in health
• -however, for the majority of differences in
  health, they are more the result of societal
  forces (poverty, racism, lack of health
  insurance, etc.) these are health inequities in
  that they are unjust, unfair, and preventable

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A warm-up exercise

• Connect the dots using 4 lines, without picking
  up your pen

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Breaking out of the box

• We all put lines around the box we live in,
  forming a skewed version of reality
• Just as you could not solve this puzzle without
  drawing lines outside of the box, we cannot
  approach the problem of inequities in health
  within the current box, a box that says (1)
  inequites are inevitable, and (2) since they are
  inevitable, we shouldnt be angered or bothered
  by their existence

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Goals for Today

• Not put you asleep
• Define health inequities and the framework of
  health equity
• Inspire you to learn more
• Keep you awake
• Talk about immediate places you can get involved
  here at UNC

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Health Equity Guessing Game

• White White High Income Insured
• Black Hispanic Low Income Uninsured
• Infant
• Mortality

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Health Equity Guessing Game
White White High Income Insured
Black Hispanic Low Income Uninsured
Infant Mortality 42 100
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How to read the numbers 42 means that 42 white
infants (numerator) die for every 100 black
infants (denominator)
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Health Equity Guessing Game
White White High Income Insured
Black Hispanic Low Income Uninsured 6
days to see doc when sick
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Health Equity Guessing Game
White White High Income Insured
Black Hispanic Low Income Uninsured 6
days to see doc 69 65
52 47 When sick
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Health Equity Guessing Game
White White High Income Insured
Black Hispanic Low Income Uninsured
Uninsured Adults
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Health Equity Guessing Game
White White High Income Insured
Black Hispanic Low Income Uninsured
Uninsured Adults 75 47
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Rates of premature birth 1989-1997
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Eight Americas

• Life expectancy ranges for subgroups of the U.S.
  population, with Asian women living longest
  (87.7yrs) and Black/American Indian males living
  the shortest (66-69yrs)
• Millions of Americans in the most
  health-disadvantaged groups have life
  expectanciessimilar to some poor developing
  countries
• Doing best at the ends of the spectrum (children,
  elderly), but not as well in the young adults and
  middle-aged

Murray C. et al. Eight Americas. AJPM. 2005 29
5S1.
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Health Equity

• Equity in health is the absence of systematic
  disparities in health between groups with
  different levels of social advantage/disadvantage
  
• - Braveman P, Gruskin S. Defining equity in
  health. J Epidemiol Community Health 2003 57
  254-258.

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Health Equity vs. Health Disparities

• Disparities/inequalities refer simply to a
  difference in the rate of disease, whereas health
  equity takes an ethical stance that these
  differences, with a few small exceptions, are
  unjust, unfair, and preventable
• ? systematic differences in health and
  disease are health inequities

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Health Equity vs. Health Disparities

• Health equity requires us to look beyond a single
  disease, a single population, focusing instead on
  the underlying inequities that lead to shorter
  and sicker lives for certain groups
• What are inequities in U.S. society that lead to
  inequities in health/disease?

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Health equity Framework is everything

• Fact For most chronic diseases, prevalence rates
  are elevated in American Indians (AI) in NC,
  comparable to the rates for African Americans
  (AA).
• Disparities/inequalities (biomedical) approach
• Question Why are AI experiencing high rates
  of chronic disease in NC
• Intervention Study AI health, tailor program to
  address AI risk factors
• Endpoint ????
• Health equity approach
• Question What social and health inequities,
  shared by AA and AI are
• leading to similarly high
  rates of disease?
• Intervention Study both groups, looking for
  social and health determinants
• of health that can be
  addressed
• Endpoint When health equity is achieved
  (e.g. rates of disease for AA, AI
• are equivalent to other
  North Carolinians)

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Health Equity vs. Health Disparities

• 3) The biomedical framework points out the
  disparities/inequalities, but as a curse of its
  ethical neutrality, it posits no corresponding
  answer regarding the solution.
• ? Health equity is a critical gold standard
  by which we must work, pointing to the goal of
  restoring justice by the elimination of
  systematic inequalities in health.

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Components of Health Inequities

• ???????

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Components of Health Inequities

• Behaviors cultural practices
• Socioeconomic educational status
• Health care delivery
• Environmental factors
• Communication barriers
• Access to health care
• Stress
• Racism/discrimination (real and perceived)
• Others?

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Three broad categories of causes of inequities in
health

• Patient factors behaviors, language barriers,
  compliance/belief in health system
• Institutional factors policies that
  discriminate (regardless of intent)
• Provider factors lack of cultural competency,
  ignorance, bias, stereotyping

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3 personal issues to consider related to health
inequities

• Race and racism
• Healthcare disparities
• Physician-industry relationships

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Race and Health

• Race continues to be the single greatest
  predictor of outcome in this country
  educational, economic, health, etc.
• Racism a system that gives certain groups
  unfair advantage and others an unfiar
  disadvantage based on skin color
• Race is not biologically valid, but very powerful
  ? discarding race as a variable is only
  possible when racism ceases to exist
• Are we willing to look within ourselves at the
  ways that racism affects us, and therefore
  affects the care that we will give?

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Inequities in healthcare

• Addressing discrimination in health care
  services has been the forgotten frontier of civil
  rights enforcement...the government has lacked
  the resources, the competence, and the commitment
  to address disparities in the quality of health
  services.
• -Physicians for Human Rights

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Inequities in healthcare

• Discrimination was everywhere, including among
  the medical and health professionals who
  furnished care and ultimately determined the
  structure, design, and operation of the health
  system.
• S. Rosenbaum

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Role of Inequities in healthcare
Adapted from V. Hogan
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Physician-Industry relationships

• Some would wonder what this has to do with health
  inequitiesask yourself this
• Q1 What drives the for-profit health
  industries (pharmaceutical companies, device
  manufacturers, health insurance firms)?
• Answer ? Maximizing profits
• Q2 Whose diseases the diseases of the
  wealthy (e.g. erectile dysfunction, PMS, IBS) or
  the diseases of the less wealthy (e.g. TB,
  malaria) of the country and the world will
  receive the most attention from these industries?
• Answer ? The wealthy, the ones who can
  afford the treatments, pills, etc.
• Fact 50 of the worlds spending of
  prescription drugs comes from the U.S.if we were
  to make a generous estimate, maybe 5 of the
  global burden of disease comes from the
  U.Smedicines and healthcare are not distributed
  in the U.S. or the world in accordance with who
  needs them, but rather in line with who can
  afford them

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Physician-Industry relationships

• If physicians and us physicians-of-tomorrow are
  getting educated and gifted by these sources,
  how can we practice evidence based medicine (e.g.
  that which utilizes the best treatments in the
  most cost-effective way) for our patients and our
  healthcare system?

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Case example The Purple Pill

• Your patient at the free clinic has symptoms
  consistent with GERD.
• You prescribe her Nexium, thinking back to the
  free samples you got during the free lunch
  and educational talk provided by AstraZeneca
  (Nexiums company) the day before
• Problem When Prilosecs patent was about
  to end in 2001, AstraZeneca launched an
  advertising blitz on its new purple pill, Nexium,
  which had the exact same active ingredient as
  Prilosec and no clinical trial data to support
  the companys claim that Nexium was an
  improvement over Prilosec.
• ?Sure, they advertised to consumers through
  T.V. ads and the such, but the primary goal of
  their campaign was to convince physicians,
  through educational lunches and free samples
  to prescribe Nexium, which the majority of
  physicians in the U.S. began to do, at a cost to
  patients and the healthcare system for Nexium
  that was 10 times as high as the cost for
  Prilosec.
• The patient leaves this encounter with a weeks
  worth of free samples and a prescription for
  Nexium, at a cost of 150 for a months supply
  (since she is un-insured), leading to her next
  headache pay the rent, or pay for the purple
  pill?

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Physician-Industry relationships

• Bottom line our patients pay for those free
  lunches we eat! Our healthcare system pays for
  the free pens we write with! And for those
  segments of the population and healthcare system
  least able to pay, these very lunches and gifts
  (and the physicians who take them) help health
  inequities to persist.
• We will not begin to solve health inequities
  until we change the role of un-checked profit
  interests in medicine this change begins at the
  level of each medical student and physician, who
  must fundamentally decide whether to be
  industry-centered or patient-centered.

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Places to get involved

• AMSA projects
• SNMA projects
• NHI
• S.H.A.C.
• El Futuro
• Thursday evening clinic at the Chapel Hill
  homeless shelter

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Native Health Initiative

• A partnership to address health inequities
  through loving service

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North Carolinas Tribes
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Education on Indigenous Health
Youth
Community Members

Coordinators
Indigenous

Communities Interns/Volunteers
Mentors Advisors

Partners

Sustainable Community Health Projects
Loving Service
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Health Equity
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Youth Empowerment
Cultural Exchange
NHI Circle of Healing
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Partnerships here on campus

• S.H.A.C.
• AMSA
• CCPS
• APPLES
• American Indian Center

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Give me an NHI
NHIs (unofficial) Cheerleaders
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NHI Principles

• (1) Educating future health professionals
  
• on American Indian health and health
• inequities
• (2) Sustainable ( community-directed)
• health projects
• (3) Youth empowerment
• (4) Cultural exchange

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NHI 2006 Summer Retreat,
Cherokee NC
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NHI 4 Project Areas

• Health interventions
• Community based participatory research
• Advocacy
• Collaborative efforts
• - created a clinical elective in American
  Indian health (partner UNC-SOM)
• - creating service-learning trip for UNC
  undergraduates (partner APPLES service-learning
  program)

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NHI Health Justice Internships

• Summer 2005 9 interns, 0 budget
• Summer 2006 9 interns, 1600 budget
• Summer 2007 26 interns, 4600 budget
• - 4 from Canada, 1 from Norway
• - 8 from other states
• - 13 are medical students

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NHI Summer Orientation, June 2006
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NHI Summer Orientation, June
2007
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Lessons learned (and still learning)

• Love is not just for Valentines Day cards
• Partnership is the key
• Stubbornness can be a good thing
• American Indian communities have many un-tapped
  assets and resources
• Youth will rise as high as our expectations for
  them

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Projects this fall

• Empowering youth to health and service A
  collaborative between Latino, American Indian and
  African American youth in the Triangle
• Day into Health inviting American Indian high
  schoolers from around the state to UNC for a day
  of fun and learning
• Lecture on cultural historical aspects of
  American Indian health by Dr. Kidwell (director
  of UNC American Indian Center)
• Lecture by Lumbee pediatrician, Dr. Joey Bell on
  unique aspects of treating American Indian
  patients

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NHI Informational Meeting

• Thursday, Aug 23rd, 7-8pm
• 113 Abernathy Hall (location of the American
  Indian Center, at the north corner of S.
  Columbia/Cameron intersection
• Cant make it, but interested in getting
  involved? Contact me!

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S.H.A.C.
Student Health Action Coalition Medical
Clinic Mobile SHAC Community Outreach
Dental SHAC HIV Counseling Health for
Habitat SALSA Native Health Initiative
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El Futuro

• North Carolinas Non-profit Resource for Latino
  Mental Health
• http//www.elfuturo-nc.org/

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• Walk in beauty