Rachana Raghupathy, Northeastern Ohio Medical University
Pranav Mellacheruvu, Washington State University
As first-year medical students, we were first introduced to the concept of health disparities by discussing those that most impacted the patients in our region. Of course, we learned the buzzwords and the definitions behind public health and the factors that influence it. However, what stuck with me most was being able to apply those concepts to my own community. More specifically, we learned about food deserts and their impact on the high obesity rates in the Northeast Ohio area—especially among minorities. The high obesity rates in certain areas can be attributed to limited access to healthy food choices and fresh produce at affordable prices.
When I dug a little deeper into this phenomenon, I learned about the process of redlining and zoning: Real estate deeds restricted certain minorities from owning property in particular areas. Urban renewal projects uprooted minority populations from their homes into overcrowded areas that received disproportionate levels of funding for housing, education, and food. With time, this lack of resources compounded to affect quality of life; health education plummeted (as did education in general), obesity rates rose, and all-cause mortality skyrocketed (1, 2).
It is no secret that a patient's background can influence their health and outcomes. Yet, we frequently see in practice that some of these nuances either go unrecognized or are forgotten altogether. For example, it has been well recognized that the incidence of cardiovascular disease (CVD) is steadily rising yearly. What has become increasingly apparent over the past decade is that certain minority demographic groups—including American Indians/Alaska Natives, Hispanics, and South Asians—are predisposed to CVD. Previous studies have shown that the cause of this predisposition is multifactorial and based on genetics, acculturation, and socioeconomic status, among others (3, 4). This highlights the need for specific, targeted, and culturally sensitive interventions. However, the efficacy of each respective intervention is dependent on the target audience, particularly considering that each demographic group presents with a preconceived set of notions, beliefs, and ideas as they relate to diet, exercise, and lifestyle. Still, too often we have seen a homogeneous approach to primary prevention of disease, including but not limited to CVD. This antiquated approach has clearly led to a disproportionate burden on minority patients.
So, What Can We Do Now?
Evidence, including that mentioned here, consistently goes to show the importance of recognizing the role of cultural background in one's medical history. It's as simple as knowing this: Certain risk factors put patients at risk for certain diseases, whether those risk factors are behavioral, socioeconomic, educational, or even cultural. With increased awareness and sensitivity placed on respect across racial groups and ethnicities, it becomes imperative that we as medical students learn not to be blind to a patient's demographics and stories. In other words, we must understand that providing health care requires understanding each patient as more than their present illness.
Once this awareness has been established, the next step is to determine which primary interventions carry the most efficacy in terms of adherence and cross-cultural competence to ameliorate disease burden in each demographic group. Recent advances have been made in the realm of “live interventions,” such as group-based classes and home health education aimed at bolstering a patient's understanding of their disease process and associated treatment needs. For example, live interventions have resulted in significant decreases in hemoglobin A1c levels in Hispanics compared to pharmacologic therapy alone (5). Yet, there remain a paucity of targeted interventions that have shown clinical superiority, and we must carry the torch forward by continuing to identify culturally sensitive future interventions.
The American College of Physicians has shown extensive support on the topic of addressing social determinants of health, including but not limited to racial, ethnic, and socioeconomic factors. In its 2018 position paper, the College has expressed support of evaluation and research on existing and rising social determinants, increased medical education on health inequity, and policy to battle these factors on an institutional level.
As the future generation of physicians, it is up to us to continue to identify culturally specific intervention strategies throughout our training to address the rising influence of social determinants of health on disease processes disproportionately affecting our nation's minority patients. It becomes our responsibility to advocate for changes we wish to see in the field based on what we see within our communities. We must learn to come together in the name of our future patients. Continue to recognize health inequities taking hold around you. Continue to have conversations among your peers and faculty and brainstorm solutions. Continue to advocate for personalized patient care and culturally sensitive interventions, understanding the patient-specific factors that influence health outcomes. Battling health inequity may start small, but it does start with us.
- Keithley D. Predicting evictions: a look back on redlining in Ohio. Ohio Housing Finance Agency. 3 October 2018. Accessed at https://ohiohome.org/news/blog/october-2018/predictingevictions.aspx on 1 August 2021.
- Stephens A. Online story map connects history and Cleveland's health. Next City. 7 November 2014. Accessed at https://nextcity.org/daily/entry/health-policy-cleveland-redlining-history on 1 August 2021.
- Burnette CE, Ka’apu K, Scarnato JM, et al. Cardiovascular health among U.S. Indigenous peoples: a holistic and sex-specific systematic review. J Evid Based Soc Work (2019). 2020;17:24-48. doi:10.1080/26408066.2019.1617817
- Al-Sofiani ME, Langan S, Kanaya AM, et al. The relationship of acculturation to cardiovascular disease risk factors among U.S. South Asians: findings from the MASALA study. Diabetes Res Clin Pract. 2020;161:108052. [PMID: 32113027] doi:10.1016/j.diabres.2020.108052
- Fortmann AL, Savin KL, Clark TL, et al. Innovative diabetes interventions in the U.S. Hispanic population. Diabetes Spectr. 2019;32:295-301. [PMID: 31798285] doi:10.2337/ds19-0006
Rachana Raghupathy is a fourth-year medical student at Northeast Ohio Medical University. She serves as an at-large member of the ACP Council of Student Members, representative to the ACP Physician Well-being and Professional Fulfillment Committee, and chair of the Ohio ACP Chapter Council of Student Members.
Pranav Mellacheruvu is a third-year medical student at Washington State University. He serves on the ACP Council of Student Members and is a student representative for the ACP Health and Public Policy Committee.
Back to the September 2021 issue of ACP IMpact