Host
Heather Simonsen, MA
Public Affairs Senior Manager
Huntsman Cancer Institute
Guest
David Wetter, PhD
Senior director of Cancer Health Equity Science
Director of the Center for Health Outcomes and Population Equity (HOPE) at Huntsman Cancer Institute
Jon M. and Karen Huntsman presidential professor in the Department of Population Health Sciences at the University of Utah (the U)
Guest
Chelsey Schlechter, MPH, PhD
Investigator at Huntsman Cancer Institute
Assistant professor of Population Health Sciences at the U
Episode Transcript
Topics by Timestamp
- Welcome and Introductions (00:51)
- How injustice leads to inequality (03:54)
- Improving healthcare access for underserved populations (08:10)
- Health equality can benefit us all (11:59)
- The importance of stigma-free clinics (18:56)
- Rising tide raises all boats (22:09)
- Achieving a future free from cancer through breaking structural barriers (24:16)
- Thank you (27:05)
Welcome and Introduction (00:51)
Heather Simonsen: Hello and welcome to [Delivering] a Cancer-Free Frontier where we asked the question, how can we deliver a [future free from cancer]? We have some remarkable guests joining us today to talk about health equity. We have David Wetter, senior director of Cancer Health Equity Science and director of the Center for Health Outcomes and Population Equity (HOPE) at Huntsman Cancer Institute at the University of Utah (the U) and a Jon M. and Karen Huntsman presidential professor in the Department of Population Health Sciences at the U and Chelsey Schlechter, investigator at Huntsman Cancer Institute and assistant professor of Population Health Sciences at the U. Dave, Chelsea, welcome. So glad you're with us today. I'd love to get to know you a little better. Dave, let's start with you. How did you get interested in this field?
Dave Wetter: I grew up in Idaho, moved all over, seven different times growing up, and got interested in working. I was very fortunate growing up, I got to work on farms all the time growing up. I got to work with lots of migrant workers and folks that were sort of passing through. And so, I got exposed at an early age to people from different cultures, different working backgrounds, etc. And when I got out of grad school, I went straight to a job at the University of Texas, MD Anderson and I did not have a career in health equity planned, but I got blown away, literally within probably the first month, by the amount of poverty we were seeing in some of the participants in studies we were working with. And that was that. Then after that I was really focused on underserved populations, folks who are living in poverty, uninsured, from diverse racial, ethnic groups, etc., and have been doing that for 28 years.
Heather Simonsen: Wow, that's incredible. And what about you, Chelsey?
Chelsey Schlechter: Yeah, I kind of came into this career by accident. I also grew up in a rural area in South Dakota and didn't really know that research was even a career you could do, let alone work in any university. I was a first-generation college student, and I was always interested in health and knew that there were impacts in our rural community that could be better than they were, but had no idea that research was a career I could do until I got into my graduate degrees and had some really great mentors who exposed me to research, including Dave. And then since coming to Utah, it's been really fun to see how we can actually partner with communities and do research that creates an impact in people's lives instead of just doing something like a bench science that doesn't translate beyond the academic article, but really focusing on our partner priorities and then actually making an impact for the people that they serve.
How injustice leads to inequality (03:54)
Heather Simonsen: Well, and the Center for Hope really does that. Tell us a little bit about the mission of the Center for Hope?
Dave Wetter: Yeah, absolutely. Our mission is actually pretty simple. We're an infrastructure and a bridge that tries to connect all the scientific expertise that we have at Huntsman Cancer Institute, at the U, and bring it to bear on problems that community partners face. In particular, we focus on health equity in everything we do. And we partner with people that are really the folks that can have a big impact on the ground with addressing health equity. So those include things like state departments of health, federally qualified health centers, or what we call in Utah community health centers, and they are really the nation safety net system. They serve people regardless of their ability to pay. We also work with the state's federally designated Primary Care Association. And working with those partners allows us to reach a large proportion of people that are facing difficulties in health care accessibility, follow up, you name it. All the way from, you know, behavioral risk factors, to screening, to early detection, to treatment, to survivorship.
Heather Simonsen: Yeah, and that reminds me of a quote you mentioned that I thought was so telling of what health equity is, that “poverty is a carcinogen,” right?
Dave Wetter: Correct. That was by Samuel Broder in 1989, the director of the National Cancer Institute (NCI) at the time. And I think that shocked the heck out of people, because there is virtually no cancer, no risk factor, no preventive intervention, where there's not a gradient based on poverty with the folks that are, you know, living in poverty, low SES, low socioeconomic status, uninsured, having worse access outcomes, etc.
Heather Simonsen: Yeah, I mean, and this strikes me as like, boots on the ground, absolutely necessary work. That really, you know, during COVID, it really exposed like, how many people do not have access to health care in Utah and the Mountain West. And if you don't, like you say, the deck is really stacked against you. Would you agree?
Chelsey Schlechter: Yeah, definitely. Across a wide range of health behaviors and screenings, insurance status is a huge, huge predictor of whether or not you're going to get screenings done and what your health behaviors look like. Which we know translates into worse health outcomes down the road.
Heather Simonsen: And really, injustice is what leads to inequality, right? So, we're talking about people where an injustice has happened, historically. And it's kind of riding that ship, if you will, steering it on a better course, right?
Dave Wetter: Absolutely. In fact, we use the term inequities most of the time because it's a little different than disparities. And inequities means that there's differences between populations and there is something unjust or unfair about that. And, you know, an example I always give is like, if I'm living in poverty, uninsured, Chelsey's got great health insurance through the U, and we both have children. Is it fair, that my child with the same condition as hers would not be able to get treated, whereas hers would? You know? That's what we mean by an inequity. It's something that there's just something wrong about that.
Heather Simonsen: I mean, absolutely. And then when you think about like those well child visits or the cancer screenings for the parents, if you don't have health insurance, you don't have money for that. And yet that is lifesaving.
Dave Wetter: Correct.
Chelsey Schlechter: And that's part of the reason why the safety net health care systems are doing such great work in Utah. They have a very large proportion of their population that's uninsured, and they provide those primary care services regardless of someone's insurance status. So, they're really the ones who are doing the good work in Utah.
Improving healthcare access for underserved populations (08:10)
Heather Simonsen: Will you tell me a little bit more about that? I'd love to know what steps you're taking, and what inroads to creating more equal access to care?
Chelsey Schlechter: Sure, yeah. I think one of the biggest things we do is that we work with the organizations who are the boots on the ground people who are doing this type of work, and we go to them and ask them about their priorities. So, if their priorities are to increase colorectal cancer screening, that's something that we want to work on, too, because we want to make it easier for their clinics to be able to provide care for patients and also easier for patients to get that care. And so, most of our research that we're talking about today, we are focused on increasing the access to already existing evidence-based interventions and clinical guidelines and practices. We're not inventing new research; we're trying to get the research that we've spent all this time identifying into the hands of the people who need it most.
Heather Simonsen: And tell me a little bit about, like, if you get a cancer diagnosis, back to your analogy, Dave, if you get a cancer diagnosis and you're experiencing poverty, how is that diagnosis going to impact your life differently than someone who is not?
Dave Wetter: Absolutely. Is it okay if I actually take you through like the whole process?
Heather Simonsen: Please!
Dave Wetter: With the community health centers that we serve, or work with, for example, their colorectal cancer screening rates are very low compared to what they should be with national guidelines, they're very low compared to the rest of Utah. And a big part of that is almost half the population there of those community health centers are uninsured. So even if you go and give them a FIT test, they don't have insurance to do a follow up colonoscopy. We're very fortunate in Utah that we have a program funded by the CDC that's led by our dear colleague, Guilherme Del Fiol, that can actually provide vouchers to get the colonoscopy. But even that step, you know, is a difficult one. And it's difficult because now, if they're living, let's just say in Green River, we have to find some place that actually has a colonoscopy facility. So, there's transportation issues, there's childcare issues, there's a lack of job flexibility. You know, those of us with the kinds of occupations that we have, have flexibility to manipulate our schedules to do things other people do not. So, there's all these barriers even going to get the colonoscopy. Now, once they do the colonoscopy, and of course if they need further care, then if they're coming to Huntsman, for example, they've got all those same issues around transportation, childcare costs, etc. Fortunately, they can usually get Medicaid at that point in time, once they have a cancer diagnosis, and then Huntsman will take care of them. But there's just all these barriers along the way that make it very, very difficult for someone to actually even receive care. And then let's not even, once you're in treatment, right? All those same things, right? If you're doing, you know, radiation, it just continues on and on.
Heather Simonsen: Yeah, and if you're trying to hold down a job or two jobs, if you don't have benefits and paid sick time or leave time, it just compounds and then the bills start coming in. Then the late fees on top of it. I mean, this is how some people end up on the streets.
Dave Wetter: The largest cause of bankruptcy in the United States, I believe, but don't, you know, I won't pretend I’m a business analyst, is medical. People have and get medical conditions and it causes them to go into bankruptcy.
Health equality can benefit us all (11:59)
Heather Simonsen: Yeah, and it's like insult to injury, really, because you're already dealing with perhaps the most difficult thing in your life. And can you help us understand how it's helping some patients? Can you think of some patients who you've been able to help through these programs? Can you give us some scenarios?
Chelsey Schlechter: Yeah, I can start. We often think about with our work that we're not only helping the individual patient, but we're trying to help the settings that serve those patients, too. So, we've done work with the safety net health care systems to make it easier for them to implement technology into their health care system. We know that most of the recommended guidelines for things like tobacco screening or colorectal cancer screening, they work best when there's some sort of change in the electronic health record. But those sorts of changes can be difficult to implement because they have limited staff who have the expertise in actually using that technology. They have limited resources in terms of things like, do they have access to fit test that they can give to uninsured patients? Because those are costs of the community health center.
We try to help the community health center also provide the best care to their patients. One project that we're working on is trying to make it easier for clinic staff to identify patients who use tobacco and then get them connected with evidence-based resources that are already being delivered by the state of Utah. So, we've helped them create changes in their electronic health records, we've provided them trainings on the resources that are available to patients. And then to follow up with patients, we've also provided them things like just giving brief reminders to patients that the resources are available has been shown to be really effective in increasing use of these evidence-based interventions. So, we use a lot of what we call low tech approaches that are available to a wide variety of populations regardless of their insurance status, socioeconomic status, geographic location.
Heather Simonsen: Well, and you mentioned the rural component, and that that really adds another layer of difficulty. And with us, you know, serving the Mountain West and the five-state area, really, those health inequities are at the top of our priority of addressing. So, I really commend the work, the really important work that you're doing. Let's talk to the person who may be thinking, “well, that's all great, but how does that benefit me?” How does that, if I'm professional, you know, an employee doing well, I have a savings; because it strikes me that we know that poverty can also lead to crime. We know that that communities are safer when people are happy and healthy. I mean, this is really work that that affects the entire community. Would you agree?
Dave Wetter: Absolutely. There is a wide variety of what are called social determinants of health or social drivers of health. And they are really about inequities, and educational opportunities, and job opportunities, and access to, you know, safe housing, and access to fresh foods. So, providing those things actually benefit society tremendously. The cost of health and health inequities in the U.S. is close to a trillion dollars that we pay extra by not having equity across different population groups and health.
Heather Simonsen: Well, and especially like, if you can't, you know, catching a cancer early when it's the most treatable rather than on the back end if somebody's got a late-stage cancer and all that that entails and the treatments. So, it's addressing those inequities upfront. Is that it?
Dave Wetter: I'm going to do a personal, hopefully it won't be TMI here, but yeah, I had my colonoscopy last summer. I had two polyps that are the kind that could translate into cancer, so they kicked up my screening schedule from 10 years to seven years. If I was uninsured in the population, there's no way in heck I would have been getting a colonoscopy. Because, you know, I wouldn't have anything to pay for that. And it's likely then, that a few years down the road some of those polyps would have turned into cancer. So, the cost is huge, because it's so you know, I mean, a colonoscopy cost versus treating colorectal cancer is, you know, magnitudes of difference.
Heather Simonsen: Gosh, I mean, that's just so important, too. When you think about that, you know, to society, and also just that human life. Thank you for sharing that, I really appreciate that. Chelsea, does that bring up any other thoughts you have, or examples of how you think your works are really making a difference already?
Chelsey Schlechter: I'm just going to add some data to the very nice story that Dave provided. In the US nationally, people who are uninsured have a 22% colorectal cancer screening rate, being up to date on their screening. Those who are insured are at 64%. So it's huge, that difference in screening. With examples like Dave, we're seeing that all the time. I think a lot of the work that we do, it brings me back to growing up in rural South Dakota and seeing what the quality of care was like there. Knowing, like, my mom getting a mammography having to drive three and a half hours because the mobile screening unit doesn't come out to the small rural town that we're in.
I think oftentimes it comes back to those little pieces that I can connect to what I've experienced. But I've hardly experienced any sort of the impact of these inequities that we're seeing with our patients. And I think one of the most rewarding pieces of the work has been working with the Community Health Centers, because day in and day out when we have advisory board to our members of the clinic staff team at these clinics and patients at these clinics and they tell us about their day-to-day experiences and about some of the stigmas they may experience in receiving care. It's just incredibly, incredibly valuable, I think, to hear and understand their perspectives, because they're the ones who are going through it.
The importance of stigma-free clinics (18:56)
Heather Simonsen: For sure. And talk to me a little bit about those stigmas and the barriers they cause.
Chelsey Schlechter: Yeah, great question. One of the projects that we have is working on tobacco. We know that tobacco is still the leading cause of death and disability in the U.S. and that we've done a great job of lowering the tobacco use rates, but really what we've done is concentrated it into populations that have low socioeconomic status and other populations. And what we heard from our patient was that they feel this sort of stigma when they come into the doctor's office. That they don't want to disclose that they use tobacco because they know they should quit and they know that it's good for their health, but it's a really difficult thing to do. So, they find it challenging to even be honest with their providers that they use tobacco because they feel that stigma. So a lot of the work that we've been doing has been trying to work with the community health centers to address that. And the providers have been so incredibly receptive to that and understanding and it's just created this dialogue between the patients and providers that I think has been really valuable.
Heather Simonsen: Gosh, and that just compounds the problem. Because if there's that shame of knowing this is bad for me, but I can't stop, and then you can't even feel like you can tell your doctor and be honest about it. Whoa! That is really tough.
Dave Wetter: Nicotine is an incredibly addictive drug. The relapse rates for opioids and nicotine basically are the same. So, it's a drug that obviously doesn't have quite the immediate consequences of a lot of other things, but long term, it's the one most likely to kill you. But it's an incredibly addictive drug. It's not a matter of willpower, it's not a matter of not trying hard, it's that your brain has actually been rewired via this drug.
Heather Simonsen: So, it's like removing that shame so we can talk about it as the medical issue that it is, that needs treatment and requires a process and a partnership with your physician. And what I'm hearing you say, too, that strikes me as so important is really that respect factor. That we're seeing everyone's life as valuable, and important, and respecting them. And where they're coming from, their communities, and meeting them where they are, right? And building that trust. Is that a big part of what you do?
Chelsey Schlechter: Yeah, I think building trust is huge when it comes to providers and patients, but I think one of the other issues is that providers are asked to do a lot and they may not know everything that they need to know. Some of our providers were surprised that there were free resources available from the state that their patients could use. And they just, they have so many other things on their plate, we ask them to do so much. Especially in the safety net health care systems where they have limited resources anyway. And yeah, for us, I feel like the providers that we've talked to have been very receptive, and they really, really want to help their patients. So, we're just trying to help give them the tools to be able to do that.
Rising tide raises all boats (22:09)
Heather Simonsen: Yeah, because they wear many hats, as you say, in those community health centers. They're probably stacked back-to-back with patients that they're seeing. What an incredible resource. What still needs to be done?
Chelsey Schlechter: We could go on and on.
Heather Simonsen: Or what's the next step?
Dave Wetter: I'm gonna get into political stuff. Like, you know, the fact that we're one of the only developed countries in the world that doesn't provide health care for all our citizens is insane.
Heather Simonsen: Yeah.
Dave Wetter: I know we don't want to put this on the podcast, but it's insanity. So, I'm trying to figure out what to say and not…
Heather Simonsen: Yeah, no, I think you can just say what you did. It's a fact though, is it not?
Dave Wetter: It’s a fact.
Heather Simonsen: Okay, so let's start with the facts.
Dave Wetter: The United States is one of the very few developed countries in the world that does not provide health care for all its citizens. That is a huge piece of the reason that, despite the fact that we pay more for health care than any other country in the world, we don't do very well on worldwide health indices. Precisely because we enable a big proportion of our citizenry to not have access to care and not have good health outcomes. If we took care of that, we would do a lot better nationally. It's a little, what's the right, you know, rising tide raises all boats. We need to just be able to take care of everybody. And that doesn't mean that you need to be doing end of life, crazy kinds of things to prolong life. It's just that we need to be able to pay for basic preventive care, basic primary care. When someone is diagnosed with cancer, we need to be able to take care of them.
Achieving a future free from cancer through breaking structural barriers (24:16)
Heather Simonsen: Well, it makes me think of like the hierarchy of needs, you know? Health care, and food, and housing, those are basic things. And for people to have those so they can live their best lives, and society is elevated because of that. Finally, I would love to hear from each of you. Why don't we start with you, Dave. What does delivering a [future free from cancer] mean to you?
Dave Wetter: It's a really, for us, it's all about having a population level impact. We want to not only impact individual people, we want to impact the entire population in Utah, Mountain West, and we want to do that by empowering not only the patients, but the places that serve them. And obviously, our work is focused so much on the settings where people that are not going to have the same kind of access to health care that we have are going to be treated. So, it's really, for us, about just getting, if half of all cancer is preventable, there's just no reason that we shouldn't be dramatically cutting cancer rates based on that fact alone. Cervical cancer, we could wipe off the face of the nation if we would take care of HPV vaccination and those kinds of things. It's just really about getting, if we could get the things we already know out there to the people that need them, we'd have an enormous impact, and really be on the path to a [future free from cancer].
Heather Simonsen: Wow, so profound. And I don't think people realize that half of all cancers are preventable. That's amazing. Chelsey, what about you?
Chelsey Schlechter: I mean, really well said. I would say for me, it's that if you, regardless of where you live, or the color of your skin, or how much money you make, you should be able to have access to the resources that allow you to live a healthy life. And that includes the environment that you live in. And I think for us to actually create the [future free from cancer], we're gonna have to do the hard work of really dismantling those structural barriers that we all put into place that have made these health inequities.
Heather Simonsen: So profound, both of you are just amazing human beings. And I know that I'm better for this experience of talking to you and learning about the incredible work that you're doing at the Center for Hope, so thank you both for being here today.
Chelsey Schlechter: Yes, thank you.
Dave Wetter: We are thrilled to be here.
Thank you (27:05)
Heather Simonsen: To our dedicated listeners, we appreciate your support. For additional resources, be sure to check out the show notes. And if you want to stay connected with us and be the first to know about our upcoming episodes, don't forget to hit that subscribe button on your favorite podcast platform. We’d truly appreciate it if you’d take a moment leave us a rating or review. Your feedback is just so important. And please share our episodes on social media. We're always eager to hear from you. Whether you have questions, comments, suggestions for future topics, or a personal story you'd like to share, please visit our website huntsmancancer.org. Thank you to the Communications and Public Affairs team at Huntsman Cancer Institute and a special thanks to The Pod Mill and Mix at 6 Studios for their help with this episode.