Statewide retreat explores health inequities and what science can do to reduce them

The South Carolina Clinical & Translational Research Institute was honored to welcome Eliseo J. Pérez-Stable, M.D., director of the National Institute on Minority Health and Health Disparities (NIMHD), as the keynote speaker at its statewide scientific retreat on “Diversity, Equity and Inclusion at the Crossroads of Translational Science” in late October. Pérez-Stable was recently honored as a co-recipient of the 2021 Service to America COVID-19 Response medal, in part for leading NIMHD efforts to ramp up COVID-19 testing availability and improve communications around the virus and the vaccine.

In his keynote, Pérez-Stable spoke about the structural rifts exposed by the global pandemic and the George Floyd protests and laid out ways in which the NIMHD and scientific researchers can help to reduce health care disparities. Afterward, researchers from across the state shared how they have tackled the problem of disparities.

Inequities exposed

The pandemic hit communities of color especially hard and exposed long-standing inequities in care, said Pérez-Stable. Twenty months of COVID-19 data shows that African Americans, American Indians/Alaska Natives and Latinos have two to three times the rate of hospitalization and death as whites. Similarly, they have lost two to three years of life expectancy due to COVID-19 compared with just one year for whites.

“Latinos and American Indians and African Americans make up almost 30% of COVID-19 cases and 45% of mortality, even though they represent only about a third of the U.S. population,” said Pérez-Stable. “This is a glaring disparity. That's not something I can say I could have predicted in March of 2020."

 

Too often these disparities are explained away as being due mainly to preexisting conditions in these populations, he said. Although these conditions play a part, they fall far short of telling the whole story.

“The real underlying cause is structural, and it's due to long-standing disparities and disadvantage and the fact that a disproportionate number of Latinos and African Americans are in public-facing jobs,” he explained.

"Latinos and American Indians and African Americans make up almost 30% of COVID-19 cases and 45% of mortality, even though they represent only about a third of the U.S. population. That's not something I can say I could have predicted in March of 2020." -- Dr. Eliseo Pérez-Stable, NIMHD director

Minority populations make up a disproportionate number of the service workers who were declared essential during the pandemic and so did not have the option to work safely at home. Some live in crowded housing conditions, making it hard to follow social distancing and quarantining guidelines. Many live in under-resourced neighborhoods and have limited access to health care, due to a lack of insurance or absence of nearby health care facilities. In short, communities of color were less able to protect themselves against exposure to COVID-19 and less able to access care once they developed the disease.

These are all examples of social determinants of health or social disadvantages that result when minority populations are subject to discrimination and racism. Included in minority populations are poor people of any color, underserved rural residents and sexual and gender minorities. When these disadvantages lead to a health outcome that is worse than the norm, that is known as a health care disparity.

What science can do to reduce health disparities

Stable next addressed how science can address health disparities.

First, he believes we need to recognize the profound impact that social determinants of health have on health outcomes.  

“Race/ethnicity and socioeconomic status – best measured by years of attained education –  are really fundamental factors in determining health,” he said. “They explain much in terms of health, and we don’t fully understand why.”

“We need to do more research on upstream societal causes, not just interpersonal or community ones, and we have projects in these areas. I think we could potentially see a decrease in disparities in the future if we address these societal and upstream factors.” -- Dr. Eliseo Pérez-Stable, NIMHD director

Pérez-Stable shared that he remembers being shocked when he learned the results of a 2015 Kaiser Family Foundation Survey: In the 30 days prior to the survey, 36% of Latinos and 53% of African Americans reported being treated unfairly due to their race or ethnic backgrounds. Such statistics reveal the personal burden that racial discrimination places on minority populations. But he thinks that researchers also need to understand the ways in which racial inequity is baked into the structure of society: where and how we work, live and access care. This will require attention to “structural” issues such as inequities in housing, schools, economic opportunity, healthy food access, public safety, transportation and green space.

“We need to do more research on upstream societal causes, not just interpersonal or community ones, and we have projects in these areas,” said Pérez-Stable. “I think we could potentially see a decrease in disparities in the future if we address these societal and upstream factors.”

Second, he stated that it is crucial that we diversify the scientific and health care workforce, citing disturbing statistics to make his point. Although African American and Latino physicians care for more than 50% of minorities, including 75% of those with limited English proficiency and more of those who are Medicaid-insured, underrepresented minorities accounted for only 14% of medical school graduates and 12% of practicing physicians. That number should be more than 50%, according to Pérez-Stable.

Finally, he noted that researchers need to engage with members of the public to learn more about their needs and barriers and said that the National Institutes of Health is increasingly supportive of such community-engaged research. He also thinks that that the pandemic taught scientific researchers that they need to step outside of their comfort zones and see what communication science can teach about crafting messaging that better resonates with the public.

Health disparities research in South Carolina

Following the keynote address, researchers from across the state shared what they had been doing to address health care disparities. The first session focused on the importance of partnering with minority-serving institutions, the second on the role race plays in childhood trauma and the third on better ways to measure and track health care disparities.

Partnering with minority-serving institutions

Marvella Ford, Ph.D., who holds a joint appointment at MUSC and South Carolina State University (SCSU), a minority-serving institution, and Judith Salley, Ph.D., of SCSU presented on their more than  decade-long collaboration, one of the fruits of which is the South Carolina Cancer Disparities Research Center, which they co-direct. The center seeks to enhance the pipeline of diverse cancer researchers, supports SCSU investigators in pursuing NIH funding of their own, offers funding for both pilot and full research projects that investigate cancer disparities, provides shared research infrastructure and encourages greater community engagement in cancer research.

 

Daniela Friedman, Ph.D., of the University of South Carolina, presented on another priority statewide partnership, the Carolina Center on Alzheimer's Disease and Minority Research, which she co-directs with Sue E. Levkoff, Sc.D. Housed at the University of South Carolina, the center provides research mentorship and education on Alzheimer’s-related disparities for faculty members at three South Carolina historically Black colleges and universities: Allen University, Claflin University and South Carolina State University. Clemson University and MUSC are also partner institutions.

Addressing race and childhood trauma

Session two focused on the long-term psychological implications of racial discrimination and adverse childhood experiences (ACEs), defined as stressful or traumatic experiences occurring before the age of 18. According to data from the National Survey on Children’s Health, a large-scale survey of U.S. children collected annually by the U.S. census, half of all American children have experienced an ACE, but Black youth are 10% more likely to have experienced three to four. It is well-recognized that the greater the number of ACEs, the higher the likelihood of mental health consequences, such as depression, anxiety and stress disorders. One of the researchers in this session presented data showing that racial discrimination could contribute to the development of these disorders but is not captured by the ACE framework, the current tool used to measure the impact of ACEs, leading perhaps to an underestimation of the ACE burden in populations of color. Others showed evidence that the baggage from such ACEs  is felt in the classroom by students and teachers alike. Like many of their students, particularly those of color, a high proportion of early care and education providers (73%)  also had a history of ACEs that, along with an already stressful work environment made worse by the pandemic, affected their interactions with their students, sapped their motivation and left more than a third thinking of quitting their jobs. Other presenters in this session described wellness programs for early educators and interventions meant to defuse the school environment and reduce student aggression by identifying inadvertent bias and addressing it. On a hopeful note, the presenters showed evidence that some early care and education providers with multiple ACEs and exposure to high degrees of workplace stress went on to develop resilience instead of mental health consequences and said that more research is needed to understand the factors behind these starkly different outcomes.  

Creating better ways to track disparities

The final session offered a wide spectrum of topics, from the development of biological measurements of nutrition health disparities to environmental justice issues around the exposure of minority populations to organic pollutants known to cause disease, the need for more equitable surgical care and the use of maps and neighborhood-level data to track health disparities across the state more effectively. One presenter discussed how she felt that the privilege walks she conducted had helped MUSC faculty members, staff and students of all colors learn to communicate better in the aftermath of the death of George Floyd while in police custody. In this exercise, participants take one or more steps forward for each social advantage and one or more steps back for each disadvantage. The hope is that, through these walks, participants can see how their progress toward their goals is affected by their degree of social advantage.

The day concluded with a series of roundtable discussions on how to build and sustain disparity research as a field and maximize its impact. Topics included recruiting and retaining disparities experts, preparing students for disparities research, improving clinical trial diversity, partnering with historically Black colleges and universities and translating research findings into policy enhancements. These discussions also offered researchers an opportunity to discuss potential collaborations.

Funding for disparities research

One of the key purposes of SCTR retreats is to encourage multidisciplinary collaborations on pilot projects related to a retreat’s topic and to offer funding opportunities. Information about pilot funding is available through Dayan Ranwala, Ph.D., of SCTR, Brett Bechtol of Hollings Cancer Center, and R. Neal Axon, M.D., of the Ralph H. Johnson Veterans Affairs Medical Center.