Addressing racial disparities in health begins upstream with racial equity in society [PODCAST]

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“Our nation is at a crossroads, but one thing is clear – the health of our country depends on the health of all individuals in it, regardless of income, gender, or race. ACPM is committed to doing our part to promote and advance health and safety for all populations. On a community level, there are several options that can be taken to maintain support. As preventive medicine specialists, I call on all my colleagues, more than 10,000 across the country, to continue to bridge the gap by encouraging policymakers to strive to eradicate structural racism and inequalities in our cities and states.”

Stephanie Zaza is a preventive medicine physician.

She shares her story and discusses her KevinMD article, “Addressing racial disparities in health begins upstream with racial equity in society.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Stephanie Zaza. She is a preventive medicine specialist and a past president of the American College of Preventive Medicine. She wrote the KevinMD article “Addressing racial disparities in health begins upstream with racial equity in society.” Stephanie, welcome to the show.

Stephanie Zaza: Thanks for having me on, Kevin.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Stephanie Zaza: Sure. I started out like many people coming out of medical school, with an idea of a clinical practice. I started off in general surgery and quickly realized that that wasn’t quite right for me. I had done a lot of public health training during medical school and went to CDC as an EIS, Epidemic Intelligence Service, officer and ended up staying for an entire career there. I spent a lot of time working in pandemic preparedness and response, also in chronic disease and other infectious disease and injury programs, so kind of a generalist in preventive medicine and public health.

I retired in 2016, and very quickly the American College of Preventive Medicine asked me to serve on the board. I did that for four years, both as president-elect and as president, and just finished up my term back in May.

Kevin Pho: Now, tell me about preventive medicine just as a specialty. What kind of workflow do you guys normally go? What’s a typical day like? What are typical cases that you see?

Stephanie Zaza: Thanks for asking. Preventative medicine is its own board-certified specialty. It includes three major specialty groups: occupational medicine, preventive medicine and public health, and aerospace medicine. We also have a handful of subspecialty areas that include addiction medicine and clinical informatics, among other things. So it’s its own group of specialties and subspecialties.

Our members and board-certified physicians in preventive medicine serve in a variety of ways. A lot of us serve in public health positions at every level: local, state, federal public health. We have a number of members who serve in the military, which wouldn’t be surprising since we have a huge aerospace contingent. We have people in occupational medicine and general preventive medicine who work in industry, in those sort of occupational medicine type of roles, but also in the health care industry itself, in the health care delivery sector, where they serve in population health roles, usually in the C-suite or just below that, in learning about the population of covered patients within that group or within an insured population. So, people in all different kinds of areas.

And then we have a large group of people who work in academic settings, teaching both public health and preventive medicine and doing their own research in clinical and population epidemiology, for the most part. So there are a number of different ways that we do our work. Our common themes really focus on populations as our patients, although many of us also maintain a clinical practice. And then a second area, of course, is prevention and moving as far upstream in the areas of prevention as we can.

Kevin Pho: Now, of course, during your term as president of the American College of Preventive Medicine, the pandemic hit. So over that past year, can you speak to some of the challenges facing preventive medicine as a specialty?

Stephanie Zaza: Yeah, and many. But I think people are aware that a number of public health physicians and public health professionals in general found the past year and a half to be very stressful, very difficult, facing an unknown infectious agent, something that none of us had ever really experienced at this magnitude and this level of intensity. And so we saw a lot of stressors just from the unknowns and having to dive in, and a lot of stressors from the way this played out in the political and social lives of people, and finding that role to be very, very difficult.

I think what’s really important to understand and remember is that no matter where our physicians were practicing, they were doing what we were trained to do, really stepping in and filling such important roles to make sure that the science was happening, that we were interpreting it correctly, and that we were moving with the science as it changed, because it was changing so fast. And that’s actually an accomplishment. When the science is moving that quickly, to be able to keep up with it and keep the recommendations associated with the science is very, very difficult to do. So I think that’s been a huge challenge for all of us in medicine, for those of us who practice in public health and population settings.

I know that for our members in the health care delivery sector, helping their systems, their health care systems, figure out how to deliver care, how to do this well, and now moving into how to protect their workers using both vaccine and barrier precautions, it’s a huge challenge. And this is what we do. This is what we are trained to do. And so it’s been an extraordinary learning year, not without its stressors, but I think this is what we train for and study and learn how to do and are prepared to do.

Kevin Pho: All right, let’s transition now into the KevinMD article that you wrote. It’s titled “Addressing racial disparities in health begins upstream with racial equity in society.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Stephanie Zaza: So the pandemic, of course, highlighted that racial disparities were a very real thing. We were seeing it play out. But this is not new. Those of us who work in most of clinical medicine know that these disparities are not new. What the pandemic did was really highlight it, and it highlighted why, in many cases, what we fail to do in medicine is to go far enough upstream.

And so the article walks us through it: There’s a good, solid body of evidence that shows that disparities are real. They’ve been happening for a long time. We also wanted to highlight the fact that the past year and a half, the pandemic and a number of racial injustice episodes that were occurring, really highlighted a lot of what we would call social determinants: how the way lives are lived in this country, depending on the color of your skin, can be very important to your health.

And so the AMA had recently come out with a strategic plan for how to confront racial injustice and inequity within an organization. So the AMA is looking inward to look at what they can do, and what we propose is that that framework is a really important framework for all of us in medicine to be looking at within our own professional organizations. I also think the framework is so brilliantly written that it can be used in a health care system. It could be used in a public health system. Any organizational structure could take that five-point plan that the AMA laid out and think about how they could address it.

We also wanted to emphasize that in preventive medicine, the area that we can really contribute to the most is pushing our profession to think and look upstream for solutions. So it’s not just about whether or not a health care delivery system is delivering good, equitable care, but how do we prevent? So many of these racial disparities are occurring in diseases and conditions that are totally preventable. So how do we move upstream? And those conditions, the situation in which those conditions play out, are preventable. So it’s another step upstream, and there we’re talking about things like housing policy, educational policy, income inequality, and how we address those things that set up conditions that allow these eventual health disparities to occur.

So I think of health disparities as lagging indicators, if you will, and these very, very upstream indicators of social equality as the leading indicators. And so if we hope to end racial disparities in health, a lagging indicator, we have to go as far upstream as we can.

And so what we’re encouraging all physicians to think about is, we’re not asking people to stop doing their clinical practice and to be giving the best possible care they can to everyone who walks through their doors, but to think about, as they’re working on the procedures and the policies and the ways their organizations function, are they thinking about whether those policies are setting up inadvertent disparities in the way people can achieve their health care? And looking even further upstream, in their own communities, are they engaged in community policymaking about healthy environments, healthy water, healthy air, places for people to be physically active, and food deserts? How do we as physicians advocate effectively in our own communities to make sure that those conditions are helpful conditions for people to live in?

So that’s kind of the crux of the article: How do we as physicians, regardless of which profession we’re in, think about moving upstream as much as we can? And it’s also sort of laying out some ground that preventive medicine and public health physicians in particular have been talking about disparities for a long time. We’ve been talking about social determinants. We can also ourselves do a lot more to push the conversation upstream as much as possible.

Kevin Pho: In your view, what are some of the barriers that are preventing preventive medicine specialists and physicians like myself from looking upstream to help resolve some of these disparities?

Stephanie Zaza: One is we’re all just so incredibly busy with the moment, right? A patient appears in front of us, they’re sick, and they need care. I think that is one big piece of it, that our practice lives are so incredibly busy it’s often difficult to take time to think about it.

I think another huge barrier is the way public health and prevention and this movement upstream is financially incentivized. It’s likely not. And so there is no way to be compensated for those hours of work that it would take to be doing that kind of advocacy outside of your practice time. We have no mechanism for that. Public health is completely funded through federal, state, and local taxes. There’s not sort of a billing line when you go to the doctor for, you know, sort of a surcharge that goes back to public health, even though everything that happens in the clinical sector will eventually have some impact on whether or not a public health system can function, whether they can do the infectious disease data collection that they need to do.

So if you come into the doctor’s office and you have an infectious disease that happens to be reportable, your physician will report that to the public health department. The public health department has no way to then charge that patient or that patient’s insurance back for doing all the work they don’t then do to follow up with contact tracing, and that’s not part of that payment system. So that’s a huge barrier.

And then the other barriers are that this is not what we’re trained to do in medicine. It’s not always what we’re really trained to do in preventive medicine residency training, right? We learn a lot about the sciences of preventive medicine, public health, epidemiology, statistics, policy, but we’re not often trained to think about, you know, how to advocate, how to lead an organization through these very difficult conversations. We’re not trained in housing policy or educational policy early enough so that it’s part of our thinking about a comprehensive look at a patient. And we’re not really taught very well about populations, thinking about populations. We’re very much focused on the individual interaction, which is obviously why most of us go to medical school.

And then often what you’ll see is a number of us will peel off either before, during, or even after our residency training and say, “You know, I want to step back and look at a bigger picture and maybe have a little bit more influence on a greater number of people.” There are all kinds of barriers to this work, but it’s also extremely fulfilling. But it can be slow to see results, which is another barrier. People, you know, sometimes in the political world, want to see results tomorrow, and a lot of what we’re talking about has very long lead times for seeing population-level results.

Kevin Pho: Now, what do you see as the path forward? Is it a matter of more education and training and funding? What do you foresee as the path forward to help resolve some of these barriers that you mentioned?

Stephanie Zaza: I think funding is one thing. You know, there’s a lot of discussion right now, and this is not unusual following a major disaster. Any disaster is going to be followed with federal funding for the groups that had to respond, whether it’s emergency services or public health, and we will see that now. We already are seeing some of that movement. Sustained long-term funding, sustained long-term funding for more people to be trained in the population health sciences. We would love to have more and more people trained, and we have lots of vacant positions for residency training because those positions are not funded.

The funding mechanism for preventive medicine training is very different from the funding mechanism for all other clinical specialties. It does not come through CMS, which is the normal way that residency training is funded, clinical residencies. Our funding comes through HRSA, through a special acknowledgement by Congress, so it has to get funded every year that way. And so we have positions that go unfunded every year. So that’s a big part of what we as a college obviously will push on.

I think that we need to do more education of our policymakers about, and this is a really ripe time for that, what public health really is. It’s not just clinical care for poor people. It is a comprehensive science of looking at populations and how diseases, and I would include in that how information and misinformation, flow through populations. So we need to do more education of our policymakers at every level about what public health really is, so that we can achieve this sort of sustainable funding and see this as part of the infrastructure that we need to build going forward. Because this won’t be the last time we see a novel virus, a new virus, jump from animal to human populations. It’s not the last time we will see other forms of public health showing themselves.

I think one of the points of our paper was that racism is a public health issue. It’s been one for a very long time, and to understand the relationship between the social determinants, including racism, is to understand public health in a much more fundamental way. So I think really educating the population, and especially our policymakers at every level, including policymakers in our own organizations, about what it will take to do this, I think, is the way forward.

Kevin Pho: We’re talking to Stephanie Zaza. She’s a preventive medicine specialist, and she’s the past president of the American College of Preventive Medicine. She wrote the KevinMD article “Addressing racial disparities in health begins upstream with racial equity in society.” Stephanie, what’s your take-home message that you want to leave with the KevinMD audience?

Stephanie Zaza: I think it’s really important for all of us as physicians to understand that we are not going to be perfect in this from the outset. We all have a lot to learn, and understanding that part of our job as physicians is always lifelong learning. This is a new thing for us to understand and learn and really dive into with enthusiasm: this idea of going upstream and really looking at how we can, instead of trying to just treat everybody that comes through the door, try to prevent as many of these poor outcomes as we can. That would be my hope for all of us, that we embrace this idea that we all can learn, and we all have a lot to do to make that happen.

Kevin Pho: Stephanie, thank you so much for sharing your time and insight, and thanks again for being on the show.

Stephanie Zaza: Thanks for having me. I appreciate it.

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