E14: 7 Domains of Health Equity

It's starting right now and we're going to be talking about health equity. Now, equity means either what you have in your bank account, but really, equity means equitable. It means everybody is treated the same. But in fact, when it comes to health equity, we cannot treat everyone the same because people come to us with different genetics, with different backgrounds of health patterns, with different stressors in their lives, and different ideas about what health really is.

So health equity is really more about wanting people to have the same opportunity for good health outcomes, which means some people are going to need more and some people need a little bit less to get the same health outcomes.

Now, the flip side of health equity is health disparity. Healthy People 2020 defines health disparity as "a particular type of health difference that's closely linked with social and economic and environmental disadvantage. And health disparities adversely affects groups of people who've systematically experienced generally greater obstacles to health based on their racial or ethnic group, their religion, their socioeconomic status, their gender, their age, their mental health, their cognitive, sensory, or physical disability, their sexual orientation or gender identity, their geographic location, and other characteristics that we historically link to discrimination or exclusion." So that's a long way of describing how we get health disparities.

Now, when it comes to health disparities, it's really the foundation of us treating health disparity so that we can get people to similar outcomes. It means we think about justice. And justice in medical ethics, the principle states that there should be an element of fairness in all medical decisions, and we need to be sure that no one is unfairly disadvantaged when it comes to access at health care.

We here at "7 Domains" believe that a woman's health and a man's health is more than their blood pressure and cholesterol, more than their measurable physical health. To be healthy, you have to be healthy in all seven domains: physical, emotional, social, intellectual, financial, environmental, and spiritual.

We also know that being unhealthy in these other domains is often reflected in physical health, rates of heart disease, diabetes, cancer, and mental health problems. It's this understanding that helps us to see what we call the social determinants of health. And this is where we know that there are disparities between some groups of people in the U.S. and their health outcomes. To help us think about these disparities and health equity, we have in our virtual studio Dr. Jose Rodriguez, who is professor in family and preventative medicine and he is the Associate Vice President for Health Equity, Diversity, and Inclusion at the University of Utah.

Dr. Jones: And after that introduction, thanks for being here Dr. Rodriguez.

Dr. Rodriguez: Thank you, Dr. Jones, for having me. I'm delighted to be able to speak to you today.

Dr. Jones: You not only have an administrative job to try to think about health equity, but you actually see patients in the clinic, yeah?

Dr. Rodriguez: That's correct.

Dr. Jones: So as we think about health equity or health disparities, when people ask you about your title or what health equity is, how would you define that? How do you talk about that to people?

Dr. Rodriguez: What a great question. I think I'll start out by saying that the title, health equity, diversity, and inclusion, was chosen intentionally. This office is the traditional diversity office for the University of Utah Health Sciences, and it was the only one for many, many years.

And so it was just a diversity office. We changed it to be a health equity office so that people could understand that the reason that we're doing diversity, equity, and inclusion work is to achieve health equity. At the end of the story is our patients, and they're also at the beginning of the story, and unless we work to have equity, diversity, and inclusion in our institutions and the people who provide the care, we will never be able to achieve it in our patients.

Dr. Jones: Right. And here in Utah, we are becoming more and more diverse, and one of our biggest diversities I think in health disparity problems is reaching out into rural areas that don't really have much healthcare and for people who getting on the road to come into Salt Lake is a terrifying thing. It's a long, long way from home.

I was looking at Healthy People 2020, which is the national efforts by the National Institutes of Health and other organizations to decide what we should be doing nationally about health, and they say that health disparities "adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group, their religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation or gender identity, geographic location." And so that means we've got our work cut out for us to try to be inclusive in the way we frame ourselves as an organization, yeah?

Dr. Rodriguez: Absolutely, and I would like to add a couple of things. When we talk about Utah as a state, we talk about our rural and our frontier counties, and by every definition they are definitely underserved. But we've got to understand that the population of those counties does not get to the population of the Latinx community in Utah.

So the rural and frontier counties have at a maximum 300,000 people, and our Latinx community alone is approaching 500,000 people. And when we think about our rural disparities, lots of times we think about rural in terms of race, and that's a mistake. As you know, our rural areas of Utah are dominated by two industries. One of them is agriculture and the other one is fossil fuels, and both of those, the overwhelming majority of the workers again are Latinos.

So it's a very interesting dynamic that we kind of have to separate these things out, but we also have to work on them together.

So a rural identity doesn't mean that it's not a Latinx identity also, and it's the intersectionality of these identities that really make it a more challenging and a more rewarding type of work.

Dr. Jones: Talk to me about intersectionality, because that's a word that I'm actually going to lead into when we use this again, but I'd like to hear from you that term intersectionality.

Dr. Rodriguez: The best way I can describe it is . . . I'll use my own example. I am a man. I'm Latinx. My family is Puerto Rican, and I am cis-gendered, and I'm straight. So you think about all of those things. Those intersections of those identities go with me wherever I go.

Think about the things that we've shared. When we go into a room to see a patient, Dr. Jones, you can't leave your femaleness outside the room . . .

Dr. Jones: No, I can't.

Dr. Rodriguez: . . . and just walk in with your race/ethnicity. I can't take my maleness and leave it outside the room. I can't take my sexual identity, I can't take my race/ethnicity and leave it outside.

So intersectionality really is the confluence of all of these identities that we have, and all of us have multiple ones. I didn't even talk about my identities as a father, as a husband, as a brother. Those are all other identities that need to be addressed when we're talking about equity.

Dr. Jones: I like to sometimes think about the concept of a tapestry, which is not a political term, but I like to think of my life or myself or my patient's life as a tapestry with many, many things going on in this beautiful colored and visuals part of this huge tapestry. But when you walk into a room to meet a patient, how do you begin to uncover their tapestry so that you can better give them care or recognize issues that might be affecting their healthcare, their emotional issues, or their identity issues? How do you uncover that when you walk into a room?

Dr. Rodriguez: Yeah, so that's a lot of unpacking that you've got to do in kind of a short time. I'm going to answer that question by talking to you a little bit about my personal history.

That is that I went to medical school in . . . Cornell University Medical College is what it was called then. Now I think it's called Weill Medicine. And while I was there, it was in I would call the affirmative action heyday. It was actually when affirmative action was not talked about as a dirty word but was actually talked about as something that was desirable.

Our medical school had a large amount of underrepresented-in-medicine students. At the time, the definition was narrower, but it was 15% for our school, which was very good at the time, and it's better than almost every medical school outside of historically black college or university medical school.

In that time, I made a couple of friends. I think I told you in the beginning that my family is Puerto Rican. My two closest friends in medical school were both Puerto Rican as well, and I will have to tell you I learned more about how to treat and how to work with Latinx patients from my two colleagues and peers in medical school than from anyone else before or after.

The point is this. When we have to kind of do all this unpacking in the room, we have to come in with both tools and attitudes that are long-standing, deeply-entrenched in who we are.

And so when I go into a room, I talk to them. I try to talk to them about who they are as much as you can. And you don't have a lot of time to do this, but in that time, you go through and kind of socialize with the patient. You ask where they live and how they're doing and all this stuff, and you present an openness so that your patient can start to reveal these intersectional identities to you.

And that's hard. We have very good research that says that physicians in the medical encounter interrupt their patients after six seconds, which is incredible. But if we were able to listen for 30 seconds, it would change who we see. And so the diversity of the medical school actually changed how I see patients.

Dr. Jones: So when you walk into the room . . . sometimes I would ask a question, "Tell me what I need to know about you so I can take better care of you." And usually I have to introduce who I am and why they're there, but in a very short time . . . I was very fortunate in my practice to have more time than most physicians have now, but I would usually say, "Tell me what I need to know about you so that I can take better care of you." And sometimes that just stopped people.

And then I have to leave an open space, meaning the quiet reign in the room, so that they then could feel that they could maybe tell me a little bit more about them. Or, "Tell me your story. Tell me a little bit more about you so I can take better care of you."

I think that I don't know people's lived experience. I only know my lived experience, but I want to be an open listener to how people's lived experience might affect their health and the way I might take care of them.

Dr. Rodriguez: I love that question and I think that I have patients who would hear that question and have to kind of sit on the silence for a little bit. And then I think I'd have patients that would say, "Well, you should know the answer to that question."

And so I think it's a great question to ask because sometimes they don't know what we need to know, and our job as skilled clinicians is to ask the questions. Sometimes it is asking about family and about relationships and about where they live and where they work and what they're experiencing right now.

Dr. Jones: Sometimes the question that I would teach my students, and you probably do too, I ask them, "Is home a safe place for you emotionally and physically and financially?" And that usually stops people for a little minute and I just say, "Is home a safe place for you? Is it comfortable for you? Who lives there? Are they supportive of you?" And just open that door, because I want to know about their social health.

And then I might ask . . . I need to know about their financial health because we're making . . . when we decide to offer a clinical solution to their issues, we need to know whether they can even afford it, even people with co-pays. So I need to begin to ask questions about their financial health.

Is that something that you manage to pull out of people? How do you find out whether they can actually pay for any of the things that you're recommending?

Dr. Rodriguez: We're fortunate to be using an excellent electronic medical record, right? Because that's really helpful, and it'll tell us if patients have insurance, if they're self-pay or not. So that gives us a clue into some of the financial stuff.

But I think I do have to ask those questions, and the way that I would go about it is, "This is what we need to do. Do you foresee any difficulties in you being able to do it?" And they'll say, "I'm worried about my insurance. You know I'm self-pay, doctor." That actually opens up the opportunity for us to look for alternative pathways to get them what they need.

Dr. Jones: Another question has to do with how much they understand of what you've just offered to them. So whether I do drawings or graphs or something, I use . . . the great thing about paper covering an examination table is you can draw big pictures. But I need to ask how much they understand.

And there are cultures in which people nod and say yes, I think particularly people who may not even understand English all that well, but they nod and I think that means they understand. But nodding may be a culturally appropriate way of just keeping a connection going.

How do you find out in people from other cultures, other backgrounds, whether they really understand what you're saying?

Dr. Rodriguez: I think our patient population speaks about 80 different languages. Some of those languages that are spoken we have interpreters who are on-site as long as there are providers in the building, and for others of those languages we have to use interpretation through some sort of technology, whether that's an iPad or a telephone or Vocera, whatever we use.

I do believe that the communication part is definitely key, but I find myself . . . especially with those who speak a language that I don't speak, I find myself drawing pictures, like you do, Dr. Jones. I find myself speaking about it and asking them to repeat back to me what they understand needs to happen and what they understand about what we discussed. And when an interpreter is present, that's a conversation that's longer, but we live in a world where equity is important, and those who need more get more.

Dr. Jones: I think when we start to talk about what particular characteristics build resilience, I think having either a religious foundation or a religious community or a spiritual domain helps people be more resilient.

But trying to find out how people frame their connection with the much greater universe . . . finding out is important. And for me, because I did reproductive health, I made babies in test tubes, I provided contraception, it helps for people to tell me if this is something that works for them within their spiritual or religious life.

Recently, there was an issue for Catholics about whether they should be taking a certain vaccine. So I need to hear what they're thinking about their healthcare and their spiritual life.

So particularly with other cultures, is there something that you can work into your 15 minutes with someone, or how does this work for you?

Dr. Rodriguez: So the reality is I never spend 15 minutes with anybody. I'm scheduled for 20-minutes visits and they tend to go over.

Dr. Jones: Oh, I'm so glad to hear that.

Dr. Rodriguez: And you do what you can. Yeah, it's very important to give people what they need when they need it. And when they're in front of you, that's the time. You give them what they need until they're done and then you move to the next patient. That takes a toll, but it's the only way that I can see doing that correctly.

And when we ask people about spirituality, sometimes that comes up in different aspects of conversations. The state of Utah still has a majority of the residents who identify as members of the church we used to call the Mormon Church. That's an identity that I share, and sometimes when we're talking it becomes clear that that identity comes out and then we can talk from a shared framework.

With people who don't share the exact same identity that I do, I think that you have to ask the question and you have to say exactly like you said. "Tell me about your belief system and how this interacts with what we're doing here."

Dr. Jones: Well, I wanted to take a little dive into health disparities in terms of health outcomes in terms of longevity or maternal mortality or incidents of diseases like diabetes are reflected in different communities by the fact that they may not have good food and they may not have reliable housing and their finances may be insecure and their family situation may be chaotic.

So our assumption is that people who don't access healthcare in a way that may serve them always have bad outcomes, but there are parts of people's lives, lived experiences, that make them resilient in the face of hardworking jobs and low health insurance and very low incomes but surprisingly resilient.

I'll just talk a little bit about the Latina birth outcomes paradox in the United States. When we think about birth outcomes, particularly babies that are born small, babies that are born early, or babies that die in the first month or two of life, Latinas have the best birth outcomes, even though they don't necessarily come from high-income families. They don't have necessarily the same educational amount that some people have. But their birth outcomes are wonderful. Not always, of course. But what about their lived lives makes their birth outcomes resilient? Do you have some ideas about this?

Dr. Rodriguez: Yeah. I have lots of ideas. I think one of them has to do with straight up biology, that Latinas are having babies at younger ages. That helps.

And then the other thing that I think about is something that's a very personal story, but I will share it with you. In 2008, it became clear that my wife and I wanted to have another child. We had three boys and we desperately wanted a baby girl. And so we did all the right things to try and make that happen, and it didn't.

And then we made the decision to adopt. We started our paperwork in 2008. Our daughter arrived in our house in 2013. She was 2 years old and we adopted her from Ecuador. It took us five years to do this, longest pregnancy in history.

Dr. Jones: This is a very wanted baby.

Dr. Rodriguez: Oh, very wanted. We were trying to adopt from my wife's home country. The point is this. When my daughter came to us, she couldn't talk and she was over 2 years old. I thought about that for a long time. She had been in the best orphanage in her country, and why was it that she couldn't talk? And then it became very clear. It's what I call the phenomenon of abrazos y besos, the idea of the hugs and the kisses and the personal physical attention.

Dr. Jones: Oh, the hugs and kisses. Absolutely.

Dr. Rodriguez: Because if you are in a great place like she was, she couldn't have the attention that my wife and I were able to give her. It was like overnight that she just began to talk and blossom and see and grow, and she was so far behind when she came to us. And so that's my theory for both the outcomes paradox in birth and for the long life of Latinas. It's the abrazos y besos. It's the hugs and kisses.

Dr. Jones: Well, you frame it in such a wonderful personal way. I've been taking care of Latinas both in Boston who are largely Puerto Rican and here in Salt Lake, which were largely Mexican, but there was so much familial support around babies and pregnancy. So pregnancy itself is less stressful if everybody expects that this is going to be a wonderful thing when there's so much social and cultural support for pregnancy and babies, and that I think decreases the amount of stress.

We know that stress is one of the major contributors to . . . and that can be financial stress and it can be emotional stress or social stress . . . to prematurity and low birth weight and outcomes that aren't ideal. But where family structures, where those hugs and kisses, add to a sense of calm during the pregnancy and the wantedness of the baby, even if it's in a low income or a young mom, the women who come to our clinic, they loved and wanted their babies.

Dr. Rodriguez: That's exactly right.

Dr. Jones: That's an important outcome.

So tell me a little bit more about longevity. Thinking about healthcare disparities, but this Latina paradox that these women who may have more diabetes and whatever, all kinds of things that are more common in some cultures than others, but they eat right and they cook forever. So tell me about living to 100 and some.

Dr. Rodriguez: I find it kind of amazing that my own grandmother is 105. On her birthday, I was sitting with her seven feet apart. She looks at me and she goes, "I am so old." She said that in Spanish. I just had to laugh because she's 105. When she turned 100, I asked her. I said, "Grandma, tell me how you get to 100." And she gave me this big long list, and my favorite thing on the list she said to have to scold and command a lot. I thought about that. I said, "Yeah, she was definitely . . ." And even in her twilight years, she was definitely a force of nature. Her daughter, my mother, is also a force of nature.

The women in my family have had power, and it's real power. I think that's another thing that we should kind of look at through a general Latinx lens as well, and that is that we as Latinos have this fama, this reputation, for being very much a machista, a macho male sexist society. But at the end of the day there are certain domains where men have no power, and one of them is in the health domain.

All the health decisions that are made in my house are made by my wife. Now, that's a weird thing. She's not a physician and I am, but yet that's how it works.

Dr. Jones: Well, let's go back to our idea of health equity and disparities. How do we do a better job, particularly in the framework that we've just been talking about and how healthy families, hugs and kisses, build resilience in health? How do we as an organization, as a healthcare organization, help build resilience into our disparate cultures that we see who are needing services and are really struggling with their health? How do we build things in for them?

Dr. Rodriguez: I think that the first thing that we have to do is recognize our role in health disparities. I think that a lot of times we feel like the bad outcomes that happen in our populations, our black population, our Latinx population, our Pacific Islander population, and especially our American Indian and Alaska Native population, those are usually seen as patient problems and the patient's responsibility. So if there's a bad outcome, it's because the patient did this or the patient did another. But really, we have to recognize what our system does.

And so, for example, let's take a look at breast cancer. Latinas do not get breast cancer at the same rates as white women. It's a much lower community rate. However, their death rates are very high from breast cancer.

And so what's the system role? So you look through it, every single one of us when somebody comes into our office, we get a little thing in our electronic medical record that says, "This patient is due for a flu shot. This patient is due for a mammogram. This patient is due for whatever." And for some reason, even though the death rate is higher among Latinas, the mammogram rate is way through the floor. So that's where we have to make our interventions, on the system-wide, because it's not an individual problem. It's a system problem. So we have to go and look at it with an equity lens, and the equity lens is the way we love our children.

I have four children, and my four children have different needs. Today is Thursday. My daughter has dance. She wants me to take her to dance. So in the hour and a half that I have to spend with kids, then I'm going to spend it with her that day.

In an equality world, with those four kids, my job would be to divide that hour and a half by four and spend . . . let's use an hour because it's easier. And spend 15 minutes a kid. But dance class is 90 minutes, so I've got to use that whole time with her.

And then the next day my son has a stomachache, and it turns out that he has appendicitis. So I take him to the hospital. I stay with him the whole time. I sit with him when he goes to the operating room. I go see him as soon as he gets out of the operating room. And so I spent two days with him out of the 15 minutes that I was supposed to do.

So we don't love our children equally. We love them equitably. We give them what they need when they need it, and that's what we've got to do with our patients.

And so if we have patients that are from these race/ethnicity groups that are having bad outcomes because they're not getting the screening, then we work with them so they can get the screening and we spend the extra time to find out what the obstacle is.

Dr. Jones: When I teach in the classroom about medical ethics, the Ethical Foundations of Medical Practice, we sometimes use this framework of what we call the Georgetown Four, or the big four cornerstones of medical ethics, which include do good. You're supposed to do good. You're supposed to not do bad, so that's two. You're supposed to support patient autonomy, letting patients make the decision from whatever framework they live in. And number four, which the medical students always forget, is justice.

We don't treat people all the same. I don't treat a 90-year-old like I treat a 4-year-old, but I want to treat them with the same values, with equity. They're not identical. So the concept that you just mentioned, working within the framework of justice within medical ethics, means we treat people with equity. We give them the same opportunities for outcomes, even though they're going to be framed very differently. I don't give them exactly the same mammogram or the exact same test because I want the test that works best for them, but I want them to have the same outcome if possible.

Dr. Rodriguez: Health equity is equality of outcomes, and I think it's important that we understand that that's where equality is and it's not in the equality of our effort. Our efforts will have to change depending on the individual in front of us.

Dr. Jones: Well, that's a perfect way to round up our time. I really want to thank you for sharing your 105-year-old grandma, and I really want to thank you for your time.

Dr. Rodriguez: Oh, it is my pleasure. Thank you for having me.

So in the end, when we look at people, what do we see? Well, first of all, we're seeing through the lenses of our own experience, our own cultural and tribal norms, but as we learn more, as we're trained to see more, we see through the lenses of historical and cultural information about that person as we perceive them to be. But finally, we should put all that away. We should put away our educational and our cultural glasses and try to see each person as they want and hope to be seen. We try to see them. Instead of through our eyes, we try to see them through theirs.

And with that last little bit, here's our health equity haiku.

Lives are tapestries
Bright colors, life ways, hard times
Let all of us shine

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