There’s a big question behind pretty much every health care debate in the U.S.: Why, despite all the money spent on health care (we’re the world’s top spender), are our health outcomes so bad? The U.S. ranks at the bottom of other developed nations. When you look at these outcomes by race, though, you start to get a hint of what might be behind these stark differences.
We see incredible disparities in health outcomes for people of color. In maternal health, for example, black women are four times more likely than white women to die during childbirth, and these disparities persist even for middle class black women. To a lesser but still to a significant degree, other women of color (Latinas, Native Americans, Asian-Americans and Pacific Islanders) experience these disparities as well. It’s not limited to maternal health either–in many other arenas people of color face worse health outcomes than whites.
This is not a new problem, and it’s been the focus of public health efforts for decades. But because of the Affordable Care Act and alarm about the high cost of health care in the wake of a major recession, the topic is receiving renewed attention. Somewhat surprisingly, there is some consensus on what is causing these disparities. Researchers, academics and providers across sectors have been pointing to what they call "social determinants of health" as the cause. Social determinants of health are things like poverty, housing, employment, stress, access to clean water and fresh food. What researchers have found, particularly by doing international comparisons, is that countries that invest more in these social services see improved health outcomes.
In the U.S., we’ve invested way more in health care spending and way less in social services, resulting in escalating costs without real benefit. Say you are a patient with diabetes. You’re having trouble controlling your sugar intake because the only grocery store in your area has little fresh food, and mostly pre-packaged processed foods high in sugars. Visits to your doctor and conversations about managing your diabetes through diet are going to do little to change the fact that the nearest grocery store with fresh produce is an hour away by bus.
Addressing this issue is going to require a system-wide change, including a challenge to the individualistic and anti-public spending philosophies popular with conservatives today. As a starting point though, there is a new movement to shift medical education in a way that might at least bring my hypothetical diabetes patient’s dilemma into the treatment discussion, and at best equip her provider with tools to address those barriers to appropriate nutrition. Helena Hansen–an assistant professor of psychiatry and anthropology at New York University, and a research psychiatrist at the Nathan Kline Institute for Psychiatric Research–along with her colleague Jonathan Metzl–chair of the Center for Medicine, Health, and Society, and a sociology professor at Vanderbilt University–are proposing a shift in the way medical students are trained.
For the past few decades, issues of health disparities and race have been approached in medical education by way of cultural competency training. The idea behind cultural competency initially, says Hansen, was listening to the patient and learning about their world view. Instead, she recounted her own cultural competency training during medical school: "Chinese patients tend to like the color red so you might want to prescribe them red tablets. Mexican families like to be together so let them all come into the exam room." In short, cultural competency training can actually serve to reinforce racial stereotyping by making providers believe they are the experts on a certain community. Instead of approaching someone from a race or culture different than their own with a desire to listen and learn about their world view, the provider might come with a set of predetermined ideas about what that person might need or want. Even if cultural competency training wasn’t reinforcing racial stereotypes, after decades of integration into medical school curricula, there is little evidence that it is effectively addressing the issues it was created to solve.
As an alternative, Hansen and Metzl are proposing that medical students train in structural competency instead. At its core, this training would be a crash course in the social determinants of health, an area that Hansen says has historically been seen as the domain of public health, not medicine. But she and Metzl are out to change that, and Hansen thinks the increased focus on holding providers (and insurance companies) responsible for the outcomes of their patients may help to push this effort along. In a Social Science & Medicine Journal article last year they argue: "clinical training must shift its gaze from an exclusive focus on the individual encounter to include the organization of institutions and policies, as well as of neighborhoods and cities, if clinicians are to impact stigma-related health inequalities."
A simple example of the possible impact of this shift is a study at University of California San Francisco, where through electronic medical records, providers were required to fill in a question about the patient’s housing status. The providers whose form included this question were more likely to include social interventions in the patient’s treatment plan.
While Hansen admits that training providers alone won’t address these disparities, she hopes that it will be the beginning of an increase in providers collaborating with other social service providers to create system-wide solutions. And it could serve another purpose: keeping physicians in the field. "There is a high drop out rate amongst physicians," Hansen says. "They feel as though they can’t have an impact on their clients’ health. The systemic barriers are too great for them to practice medicine in a way that makes a difference." Hansen thinks provider burnout could be eased by structural competency work because individual practitioners might actually feel like they are helping their patients in more systemic ways.
While Hansen and Metzel have seen interest in their proposal over the last few years, it’s clear that a number of barriers exist to getting this training implemented in medical schools. A primary one, and likely part of why cultural competency training has been distorted from its original intention, is ideological. "We’re really going against the grain pushing something that takes the focus off the individual’s responsibility for their own health," says Hansen. Another barrier is research. There have been few studies on structural competency, in part because medical research is often funded by the pharmaceutical industry. Medical education is not a product that can be sold for profit (although cultural competency curricula have been prepared and packaged by some companies). Without studies showing the efficacy of the training, it’s harder to make the case for it–creating a chicken or the egg paradox that makes it tough to move forward. But there is some hope for this concept: the fact that most of the interest in it has come from a younger generation of new providers, says Hansen.
One can only hope that we’re at a tipping point when it comes to tolerance of these major health disparities, and that looking beyond individual patients toward the political, economic and social environment which they live (in many ways an intersectional approach to health care) can bring us one step closer to closing these gaps.