This Q&A was originally posted by CURA Strategies.
This year World Health Day and National Minority Health Month share not only the same timeframe, but a similar theme: Building a Fairer, Healthier World.”
CURA Strategies sat down with Howard Mosby, of H.E.A.L. Collaborative treasurer, to get his insights on what topics he believes should be at the center of the discussions around these holidays, and how we can best educate ourselves and bring awareness to these topics. Howard, an 8-term member of the Georgia House of Representatives who served on the House Health and Human Services Committee, among others, focused on legislation to increase access to healthcare for the underserved and uninsured populations of Georgia. Now serving as the board member and treasurer of H.E.A.L. Collaborative, he continues to fight for increased access and resources for minority populations.
As we observe these holidays and consider the best paths forward to achieving health equity, we do so knowing that this conversation has never been more important. As Howard reminds us, “It takes all of our voices to make strides in this space.”
CURA: The theme for this year’s World Health Day centers around health equity. What does health equity mean to you, and how do you envision we build a fairer, healthier world for everyone?
Howard Mosby: At HEAL, our vision for health equity is that communities of color are as healthy as every other community and that health statistics are equitable across the board. Our mission is to ensure that equity is rooted in all parts of healthcare, from treatment access to delivery to policymaking. Providing educational resources is a big factor in how we address that.
Healthy equity as a whole is a complex problem and in order to achieve it you have to start at the beginning of the problem, and right now in many ways we are attempting to skip over the systemic bias and unscientific merit that created this equity gap, and pretend that the problem appeared out of nowhere. We have policymakers and health care leaders attempting to just create a level playing field thinking that will fix this issue. However, in my estimation, we have to go back to the beginning and address the issues that got us to where we are today such as the systemically biased policies and ill-conceived scientifically based stereotypes that have created this landscape where minority communities are disproportionally unhealthy compared to others.
To get minority communities healthy, we have to be honest about how we got here. We have to acknowledge that there was systemic racism and bias in every medical journal and treatment pathways from the start, and by extension still is due to those norms and stereotypes based in how medicine evolved to create the current treatment pathways and start over for communities of color, period. And only then we can start undoing the factors that got us here today.
Take chronic kidney disease, for example. A metric doctors look at when evaluating a patient is an Estimated Glomerular Filtration Rate (eGFR) test, which determines the level of kidney function. There is a multiplier that estimates the kidneys of African Americans as stronger than the kidneys of other ethnicities, which disproportionately impacts African Americans in that they would require a higher value on the test in order for doctors to consider their kidneys lower functioning, excluding them from an accurate diagnosis, or from a diagnosis altogether, so that by the time they are diagnosed they have to go right to dialysis. This is a disparity that was not addressed until 2021, but many health systems are still using that inaccurate data, and we have to fix that data from the source where it generated in order to eradicate it across the board. Putting new policies and/or therapies in place are supposed to be great because they’re founded on the most recent data, but if those policies or therapies were founded on biased data, the new policies and therapies will be built on this unstable foundation, and the outcomes may not achieve the expected results (lower cost or decreased mortality) thus causing the medical community to roll back those efforts and give up resorting back to the old norms.
Accountability is key—until we start calling out these institutions by name who set these guidelines, like the U.S. Preventative Services Taskforce, and groups in charge of setting parameters on screenings, like the National Comprehensive Cancer Network, we will continue to see the impact of this systemic racism. There are not enough African American patients that are part of the decision-making process in setting these guidelines and parameters that should be present to speak on decisions being made for patients of color. It can’t be ignored that screenings are where money is made, and much of the decisions in our system are made on the factors of cost and time.
Another example where we see this is in the screening of social determinants of health, i.e. what people do for a living and where they live, among other factors. If a patient diagnosed with a bipolar disorder is prescribed a morning medication with a sleeping agent that would make them drowsy at the dosage required, but their occupation is driving a city bus during the day, we can recognize a potentially fatal error in that prescription. However, social determinants like occupation are often not taken into consideration in the decision-making process of how doctors are prescribing medications as much as whether a patient can afford a certain medication or treatment plan. We have to consider how care is delivered and how medications are prescribed to fit the whole picture of someone’s life in order to prevent entire populations from being discounted.
Ultimately, anything you do from an equity standpoint must consider time or money—or both—and many organizations are disincentivized to make any changes that would impact those two factors.
C: What health disparities do you believe are the biggest barriers to minority health today?
HM: Overall trust in the system. That’s what we work on at HEAL, demystifying information by providing people with resources from experts so they know they’re getting the correct information in a way that’s understandable and accessible. Ultimately patients are willing to pay for something, like a medication or a treatment, that they believe in. However, they are not willing to overpay for care that they don’t believe will work for them. So putting credible, digestible information in the hands of the community is vital in order to help them make those decisions.
The COVID-19 vaccine is a very relevant example of mistrust in the system that we’re seeing play out today. Communities across the board were wanting to participate in the vaccine trials and early adoption of the vaccine, until a few key influencers—including those at the highest levels of federal leadership—started saying that the vaccine was dangerous, which permeated across social media and other channels of communication. Information moves lightning fast today, and their words sowed just enough doubt in the system that you then saw a dichotomy in some communities trusting the vaccine over others. That’s why getting accurate information out there to communities of color is so important.
C: What’s one significant change that you think needs to happen in healthcare?
HM: As a society, we need to think about how our health care system, and this even applies to our education system, can exist either as a for-profit system, or for a not for profit – a bottom-line focused system. As long as we have shareholders that want a return on their investment, or as long as funders of healthcare (governmental or foundation funded) seek positive margin results, we’re not able to give our (disadvantaged and disincentivised) populations the care that they need.
Healthcare cost and inflation and thus pricing are growing at rates faster than the consumer price index in most industries in this nation. Moreover, there is likely not a single asset that you own or that you’re not willing to sacrifice to save your life or the life of a love one. And because we live in a free market society, healthcare systems that are in the for profit space are as capitalistic as an industry can get. And if you get your healthcare in one of those facilities, and it’s the only type of health care available to the citizens in an area, those systems can be ruthless in demanding the liquidation of any asset one may have to live… and that’s a choice that many are facing today. Take for example physician groups or health care systems that own their own physician practices, such as nephrologists who own their own dialysis centers, who are incentivized to send patients to dialysis because that’s where the patient care reimbursement is. But we have to realize that not all populations have access to the same high-quality care from these practices. That’s when you see a rationing of care and ratcheting up of the cost of care.
Hospitals earn money from procedures and surgeries, so diagnostic procedures like MRIs and ultrasounds, or specialized surgeries are high-cost items. There are no systems or safeguards in place to protect those who don’t have insurance, or aren’t covered by some government payor like Medicare, and so they are left vulnerable. We need to create bumper guards around health care costs as a function of access. Some exist, but not enough to make health care accessible to the masses, especially for disadvantaged and underserved minority populations.
C: What can community leaders, including policymakers and church leaders, do to help improve health outcomes for the minority populations they serve?
HM: People need resources to help them navigate our health care system. Health care systems need to acknowledge their efforts in making the environment difficult to navigate and change their approach.
If something happened to you today and you found yourself in a hospital environment that is completely foreign to you, how would you navigate that? How would people with differing levels of experience and education navigate that environment? How would those who don’t believe they are deserving of certain levels of care navigate it?
Take, for example, a family with a loved one in the hospital for treatment who has just been informed that their relative has developed bedsores. First, why does my loved one have bedsores? Second, what can be done to address this? Without the resources to know who their advocate is, and what their options are, and with a heavy dose of mistrust in the system, the only way they may know how to address that situation is with an emotional response, which historically only serves to reinforce certain stereotypes and that feeds that narrative that excellent proper care is not warranted or provided.
Another example we are all becoming familiar with is the COVID-19 vaccination process, where we’re all being forced to navigate the state and local health departments to learn when it’s our time to get a vaccine. A number of health systems have been penalized by the federal government for handing out vaccines to patients who did not fall under the current distribution phase—a moving target that can sometimes change by the day—and now have fewer vaccines to distribute to their populations as a result. Which populations get penalized? Usually the poor and disadvantaged.
Community leaders such as policymakers and church leaders need to advocate for the human resources, creating the culturally appropriate environments to help people navigate this space that is full of unfriendly acronyms and complicated language and systems. We need to put care back into health care.