A new health equity major reflects what alumnae are doing in the field
By Jessica Langlois, MFA ’10
For the past 18 years, Maurie Davidson ’63, a licensed clinical social worker, has been a volunteer faculty member at the Geffen School of Medicine at UCLA, teaching third-year students to consider the human condition of their patients, not just their illnesses. It’s the one time in medical school when medical, dental, and nurse practictioner students consider the interrelationship of physical and mental health—from social biases to economic systems that can affect quality of care.
“We want to embark on an understanding of people, the cultural backgrounds they come from, the environment they live in, the environment they’re going back home to. Every individual patient comes from a unique set of circumstances,” explains Davidson.
Four years ago, Davidson had an eye-opening moment when students responded to a question about cultural disparities they had noticed in the course of their training. Three out of the eight students wrote about the lack of information provided regarding treatment of transgender patients. According to a 2014 survey by the Human Rights Campaign, 70 percent of transgender or gender-nonconforming patients say they have experienced some type of discrimination in health care. And although both the Association of American Medical Colleges and the University of California, San Francisco’s Center for Excellence for Transgender Health have released guidelines for treating LGBT and gender non-conforming patients, many major medical schools and hospitals still lack standard clinical training.
Davidson immediately advocated for adding information about trans health to the curriculum. Her colleagues agreed and, by the following year, they had launched a transgender health module in the second-year of the doctoring program.
LGBT patients are just one of many groups who encounter health-care disparities in the United States; and, increasingly, the concept of health equity is being raised in the public health field. This involves acknowledging that the greatest threats to good health for Americans are preventable diseases that often stem from nonmedical factors, including lack of safe housing, steady employment, and quality education, as well as discrimination or bias.
Poverty, language barriers, social or geographic isolation, and institutional racism also play a role, and many of these factors contribute to higher rates of chronic illness and disability among marginalized groups. The Kaiser Family Foundation reports, for instance, that Native Hawaiians and Pacific Islanders, African Americans, American Indians, and Hispanics are more likely to be diagnosed with asthma, diabetes, or obesity than whites—conditions that can be caused by limited access to nutritious foods, lack of places to be physically active, and environmental toxins. Similarly, even though women have a higher death rate from heart disease than men, they are less likely to get diagnosed or treated.
“Good health shouldn’t depend on your zip code, race, or gender,” explains biology professor Jared Young. “There are inequities across those kinds of categories that don’t need to exist. They shouldn’t exist, and there are ways that we can address them.”
Those ways include: improving education and awareness for medical professionals, creating more pathways for underrepresented minorities to enter the field, incorporating social services into medical programs, making health care services more accessible to low-income communities, and increasing trust between providers and patients.
Last year, Mills became one of the few undergraduate schools in the country to offer a major in Public Health and Health Equity that aims to prepare students to create these kinds of positive change. The program offers two courses of study: one emphasizes the science of medicine; the other incorporates classes in public policy, sociology, economics, psychology, and ethnic studies for students most interested in advocacy, education, policy, and law. Young and Provost Julia Chinyere Oparah, who is also a professor of ethnic studies, conceived of the program over dessert at a faculty event in 2014, as they brainstormed ways to keep underserved minorities from dropping out of STEM majors. Many undergrads on the pre-med track at Mills choose the field, Young explains, because they or their families have had negative experiences with the medical system and they are driven to improve that experience for others. But after a year or two, when students don’t see those passions reflected in their biology or chemistry coursework, many end up transferring to ethnic studies or other degree paths. Young refers to such students as “STEM refugees.”
The program attracted 12 majors in this, its first year. But many Mills alumnae have already been deeply entrenched in the movement for health equity for decades.
Davidson is one of those. The mother of a lesbian daughter who is also a physician, Davidson had been an active member of PFLAG for years. But, at about the same time as her students called attention to the lack of information on transgender health, she joined the Gay and Lesbian Medical Association and began learning from experts in the field. She also learned that the Affordable Care Act requires the coverage of health-care needs of transgender people—including hormone therapy, mental health counseling, and procedures, such as plastic surgery, not directly related to gender reassignment surgery but still tied to gender expression for many people.
Because bias and misunderstanding persist within the medical community, the transgender health module in UCLA’s doctoring program focuses on improving cultural competence of health care professionals, which translates to improved patient experience. First- and second-year medical students at UCLA typically learn to conduct comprehensive medical interview with actors playing the role of patients—an exercise that cultivates clinical knowledge along with empathy and human connection. Davidson and her team brought in 10 transgender actors, for a slightly different assignment–instead of roleplaying, these actors related their own experiences in seeking medical care.
“When you’re working with a trans person, it is a simple matter of respect to ask, ‘What pronouns do you want me to use for you?’” explains Davidson. “There’s a great deal of variation on the transgender spectrum; this simple question can make a big difference.” Understanding such appropriate behavior is an important step in building a beneficial doctor-patient relationship.
Davidson is proud to say that, at this time, no student can complete a UCLA medical degree without learning about transgender health, and she points out that the program also makes the medical field more welcoming for diverse individuals.
One year, Davidson noticed a male nurse practitioner student become visibly relieved after she introduced herself as a PFLAG mom and passed out information on gay and trans health. He later told Davidson he was gay and caring for HIV patients; up until then he hadn’t felt comfortable coming out to his medical school community.
It’s an important shift. The Congressional Black Caucus Health Braintrust recently stated that a states that a lack of workforce diversity—that is, not enough doctors who look like the patients they are serving—is a serious factor contributing to health disparities among minorities. The concept applies in LGBT and transgender health care as well.
“These students will become role models,” says Davidson. “They’ll create a positive example for their patients and for colleagues throughout the medical field.”
Most health disparities are influenced by pervasive social conditions that exist outside the walls of a hospital or clinic. Often, health data points to greater inequities in a community.
In 2009, Pat Temple Gabbe ’64, a doctor and pediatrics researcher, served on the Ohio governor’s task force on infant mortality. At the time, the state of Ohio ranked second to last in the country for infant mortality. In Franklin County, where Gabbe lives and works, each week two to three babies die before reaching their first birthday, and the rate is nearly three times as high for African Americans than for whites. The task force found that many of the infant deaths were due to preventable causes: key factors contributing to this grim number include poor pre-natal care and nutrition, substance abuse, stress, long working hours, and unsafe sleep habits for infants.
“There’s a lot of injustice in these numbers. I thought, ‘Why can’t we change this?’” says Gabbe. Within a year, she launched Moms2B, a community program in Columbus that educates and supports pregnant women and mothers living in poverty and connects them to medical care as well as other resources.
“We’re focused on understanding the African American woman living in an urban area and addressing the social factors that she faces,” says Gabbe. “We get our moms connected to medical care in spite of barriers like lack of transportation and insurance, and long waiting lists at some clinics or practices.”
Moms2B is supported by Wexner Medical Center at Ohio State University, and is staffed by pediatricians, obstetricians, nurses, social workers, and medical dietitians from the university’s OBGYN unit. This coordinated team reaches out to women who might not otherwise go to a clinic or hospital during their pregnancy and creates a space for women to connect with one another and get important information about their pregnancies.
Gabbe says sometimes black women aren’t treated with respect in the medical field, and that can discourage them from seeking care. Research supports her statement: A 2013 study in the Maternal and Child Health Journal found that the majority of black women with limited incomes seeking pre-natal care felt they were treated differently because of their race or because they had public insurance.
Most of the women who come to one of Moms2B’s six community centers in Columbus are in their 20s, haven’t graduated high school, earn less than $1,000 a month, and already have two or three children. Most live in subsidized housing, but 25 percent have no housing at all, says Gabbe.
“They try to work as much as they can, but usually they’re in temporary jobs that don’t have benefits, so they rely on Medicaid,” Gabbe explains, adding that the Temporary Assistance for Needy Families program has a 36-month limit, and most of her clients have already used up their funding.
Moms2B offers material assistance, education, and a network of emotional support. On a typical day, women enter the center in their community and can take whatever clothes or supplies they need from a donation table. They help themselves to a healthy snack and are provided with a five-dollar grocery gift card. A staff member is sure to welcome each mother and ask how they and their children are doing.
“I don’t want any mom sitting alone,” says Gabbe, who seeks to create an atmosphere that will encourage mothers to keep coming back during and after their pregnancies.
Then older children play games with volunteer child development students, while moms and younger children gather in what’s called the “sister circle” for lessons and to answer the day’s question. Recently, the question was, What makes you happy?
“Some people said I love to swim, or I like to be with friends; but one little girl said, bacon!” says Gabbe. “We laughed, but the question was tied in to a lesson on post-partum depression and the baby blues.” That day, the moms to be also learned about the importance of nutrition and relaxation and preparing for labor and delivery; the session finished, as it always does, with a healthy meal for the whole family—moms, kids, and dads together with the Moms2B team.
Since opening, Moms2B has served over 1,000 women who are pregnant or post-partum. While the infant mortality rate in Ohio is still high, the rate in the Columbus neighborhood where Gabbe started Moms2B has declined dramatically in the program’s first four years.
“Across the US, we in the medical field do a great job with medical conditions pregnant women face, but we are not tuned in to social factors that underlie their pregnancies,” she explains. “It’s difficult for women living in poverty to relate to the medical system, so we try to bridge that.”
Policy issues also create significant effects on the health of populations. As the federal government argues and negotiates the state of health care in our nation, many Americans suffer the consequences of being unable to afford insurance or pay for direct services. Although the number of uninsured, non-elderly Americans dropped by 50 percent between 2013 and 2015, 28.5 million Americans are still uninsured.
In Virginia, which has a strict Medicaid policy and declined to expand its Medicaid coverage under the Affordable Care Act, income and other eligibility limitations leave 747,000 Virginians without any form of insurance. Most of them are working poor who fall into the state’s “coverage gap,” meaning they don’t earn enough to purchase insurance through the state-subsidized marketplace, but also don’t qualify for Medicaid because they are childless, undocumented, or earn more than 133 percent of the federal poverty level.
This is the population that the Arlington Free Clinic serves.
The clinic was founded in 1994, after the Arlington Medical Society convened a committee to seek a solution for the many patients who sought care but couldn’t pay for it. They came up with the idea for a free clinic staffed by volunteer doctors. Nancy Sanger Pallesen ’64, who had been an executive director of services for a mental health provider in Virginia and Maryland, took on the task of heading the clinic as its founding executive director, raising the funds needed to keep it running, and recruiting and managing the volunteer staff.
It could be said that social justice in the medical field is encoded in Pallesen’s DNA. Her father was a physician who sometimes traded his services for a chicken dinner when patients couldn’t pay. She also was greatly influenced by her grandmother, birth control activist Margaret Sanger, who told her, “You’re here to make this world a better place, so figure out how to do it.”
In its earliest days, the Arlington Free Clinic opened once a week out of the nurse’s office at a local middle school. They saw 12 patients the first night. Now, 23 years later, the clinic serves about 1,600 patients a year and includes 500 volunteers, 30 paid staff, and a licensed pharmacy.
Pallesen recognizes that the clinic benefits from its location. Arlington County, which sits on the Potomac River directly across from the White House, is one of the wealthiest counties in the nation, and she had no trouble finding doctors to volunteer their time and skill. A local orthopedic surgeon does all the clinic’s knee replacements, seeing around 100 patients a year at no cost.
Like Moms2be, the clinic’s model of care is based on a “whole person” model that looks beyond a patient’s immediate ailment to the multiple factors that contribute to long-term health. Pallesen, who recently retired after over two decades heading the clinic, explains that, as the clinic’s clientele grew, they expanded their services beyond primary care to include OBGYN, psychiatric, and dental services, as well as endocrine care for people with diabetes. They also connect patients in need to county services like food stamps, housing assistance, and hospice.
Many people who are uninsured rely on the emergency room for primary care or treatment for chronic conditions. It’s an unsustainable model that is both ineffective and costly. “People can go to the emergency room and be taken care of for that one visit, but they would be sent away with no follow-up care, just a prescription,” says Pallesen. “If you have a chronic illness, you wouldn’t live.”
And yet, insurance coverage in itself is not a guarantee of access to care.
Amber Kemp ’05, MBA ’08, vice president of health care coverage at the California Hospital Association, is an expert on the interactions between government-funded insurance programs and the state’s health systems.
While California’s uninsured rate is now 7.1 percent, less than half of what it was in 2013, one in three residents—and half the state’s children—are covered under Medi-Cal, the state’s Medicaid program. For these people, many doctors remain out of reach.
It’s a question of economics. “Payments to providers are so low, a lot of primary care physicians are not accepting new Medi-Cal patients,” explains Kemp. “As a result, we essentially have a primary care physician shortage throughout the state.” The gap is even greater in rural communities, which have fewer medical facilities and a higher-than-average percentage of Medi-Cal patients.
Still, Kemp is optimistic about the strides California and the nation have made in health care reform, particularly in the shift towards addressing the connections between better patient experience, improved health outcomes, and reduced per-capita cost.
“We’re recognizing that behavioral health is an important part of a person’s whole health; social factors also are increasingly being considered,” says Kemp. “A patient may not adhere to their medication if they don’t understand the instructions, for example; or they might miss follow-up appointments if they don’t have transportation.”
The United States currently spends 17 percent of the GDP on health care, but invests only half as much on social services. Meanwhile, the country has a lower life-expectancy rate than most industrialized nations, and life expectancy is demonstrably shorter for racial and ethnic minorities, those living in rural areas, and other marginalized groups. Experts like Kemp assert that increased focus on social services will improve health outcomes and reduce the cost burden on individuals, institutions, and the nation.
“Other countries invest far more in social services and supports and less in medical care,” says Kemp, whose family received support from a variety of public programs aiding vulnerable populations while she was growing up. “As the beneficiary myself of nearly every government-sponsored health care and educational program, I know firsthand how important these are to children and families.”
That personal experience has directly affected her work as a policy expert implementing public health care programs in both the public and private health sectors. “I have empathy for folks who are on the other side,” she says. “I understand what it’s like to be in their shoes.”
The new Mills major in Public Health and Health Equity is geared toward people like Kemp—underrepresented minorities who are passionate about transforming the health care field—and will give them the tools to understand and address the complex issues that affect the. Professors Young and Oparah wanted to offer a program that speaks directly to these students and encourages their deep-seated motivation to create change.
“We want to infuse the healthcare system with a greater sense of social justice,” says Young. “This is the Mills version of what medicine should be.”