A new way to fight health disparities?

I have another article up at Colorlines today, this time about a new movement in medical education to address health disparities: structural competency training.

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.”

The Radical Doula Guide, although I didn’t know of the terminology yet (it was coined by Hansen and Metzl) is in many ways a structural competency primer for doulas. We can’t understand someone’s lived experience without first understanding the social and political systems that influence their lives and their health. The idea of cultural competency has always seemed a bit narrow to me, and I think an education in how racism, poverty, sexism, etc impacts health will be way more useful.

I’ve been obsessed with talking about the extreme disparities faced by women of color when it comes to pregnancy and birth, and I’m trying to spend my time looking at potential solutions to the problem, rather than simply the problem itself.

Here’s to hoping this kind of education becomes the norm for all types of providers–midwives, doctors–and doulas too.

Read the full article here.


American College of Nurse Midwives urges quality care for trans and gender variant people

Anyone else feel like it really is a tide that is turning these days? The American College of Nurse Midwives issued a statement in support of working towards quality, competent care for trans and gender non-conforming people. Woo-hoo! While it may seem like this is a no-brainer, it’s actually a big step in the right direction for ensuring that trans people can find medical care that doesn’t try to pathologize trans identity, and hopefully someday with providers who understand the needs of trans folks.

From the statement, issued in December of 2012:

It is the position of ACNM that midwives:

  • Exhibit respect for patients with nonconforming gender identities and do not pathologize differences in gender identity or expression;
  • Provide care in a manner that affirms patients’ gender identities and reduces the distress of gender dysphoria or refer to knowledgeable colleagues;
  • Become knowledgeable about the health care needs of transsexual, transgender, and gender nonconforming people, including the benefits and risks of gender affirming treatment options;
  • Match treatment approaches to the specific needs of patients, particularly their goals for gender expression and need for relief from gender dysphoria;
  • Have resources available to support and advocate for patients within their families and communities (schools, workplaces, and other settings).

That all sounds great to me. It’s actually a really fabulous statement, much more comprehensive and far-reaching than the one issued by the American College of Obstetricians and Gynecologists last year. It addresses the need for education about transgender issues in midwifery education, and even the fact that it enumerates the different identities: transgender, transsexual, gender variant, gender non-conforming, is a big step that I haven’t seen many other medical bodies take.

This is my favorite part:

As many as half of gender variant individuals report having to educate their health care providers about their health care needs, but gender variant people do not by default have unique or complicated health issues. Most members of this community require the same primary, mental, and sexual health care that all individuals need. The most important thing all midwives can do to improve the health care outcomes of gender variant individuals is to use their skills to provide care that is welcoming and accessible.

Amen to that. I would say the same thing for doulas.

It’s really incredible to witness the strides being made, while still acknowledging the serious barriers and often really challenging conditions that trans people face in the United States. A longform journalistic article I wrote for Political Research Associates was recently published, and in it I explored a new ad campaign run by the DC government that tries to address discrimination against transgender people by promoting trans respect and awareness. It was a pleasure to interview the many folks involved in working to improve conditions for trans people–it’s clear just how much incredible activism has been happening, primarily led by trans folks themselves. But it was also a reminder of how far we have to go, and how trans and gender variant people face serious discrimination in pretty much every area of life. You can read the article here.

Lastly, another new resource from a group I used to work for, The National Latina Institute for Reproductive Health, about creating health care that is inclusive of trans and gender variant Latin@s.

h/t Claudia Booker for the ACNM link

Race-based health disparities and the politics of difference

My latest column at RH Reality Check discusses the fact that last week was the tenth anniversary of National Latino AIDS Awareness Day, and delves a bit into the causes of race-based health disparities.

I was inspired to write about this topic after hearing scholar and Professor Dorothy Roberts speak at Barnard College. She’s the author of two incredible books about race and health, Killing the Black Body–an absolute must read for anyone interested in reproductive rights, and Fatal Invention, her most recent book (which I reviewed here last year).

Fatal Invention takes on the question of race and genetics, and addresses the growing movement which tries to connect race-based health disparities to genetic difference, despite very little evidence to support these claims.

From my column:

Latinos do not experience higher rates of HIV and AIDS because of any unique genetic propensity or susceptibility toward the disease, but instead because of the social and economic reality faced by Latinos that lead to higher rates of HIV infections and AIDS-related illnesses. Things like lack of access to health care, homophobia, lower rates of condom use, and language barriers among other causes.

To some it may seem absurd to think that anyone would argue that race-based health disparities are a result of genetic or biological differences among racial groups, but the fact is this argument is on the rise, and it isn’t new. Studies with these kinds of claims grace the front page of the New York Times science section on a regular basis. Rather than acknowledge disparities, some want to highlight the concept of difference—meaning that racial groups have biological differences that account for these statistics, rather than blaming the conditions of racism that shape our lives and our health.

This distinction feels as important to highlight as the problem of race-based health disparities themselves, particularly in an era where the FDA can approve a race-specific drug (BiDil, a drug for congestive heart failure) with little scientific evidence backing the claim that it successfully targets African Americans over other groups.

Our work to address health disparities needs to be based outside of the laboratory or pharmaceutical industry, and instead placed in the broader social context that is likely to blame for these disparities in the first place.

Precisely because I talk so much about these race-based health disparities, I think I, and all of us, need to do a better job of explaining the likely cause. Because if not, in our silence, the assumption can be made that the statistics are simply a matter of differences. This obscures the real and horrific injustice of poverty, racism and all of the other social factors at play.

“Model Minority” myths and maternal health

A belated post about my column last week for RH Reality Check, in response to the Pew Foundation report about the “rise of Asian Americans.”

Last week’s report from the Pew Research Center, The Rise of Asian Americans, has stirred up much controversy. Many advocates in the Asian American and Pacific Islander (API) community are arguing that the findings further a damaging idea about Asian Americans — the “model minority” myth. Advocates have said that these myths, which include the idea that Asian Americans are wealthier, more educated, and happier than other groups (all purported in the Pew report) are damaging because they hide the real challenges that exist for Asian Americans and Pacific Islanders, in particular for certain national and ethnic minorities that fall under the API umbrella.

One place this “model minority” concept can have negative implications is in discussions of health disparities. Whether due to population size or misconceptions about the health of Asian Americans, we do not often hear about the specific health disparities facing the API community. In the discussions about race and health, people of color are often grouped together, and disparities are talked about in terms of the gap between white people and people of color (Asian Americans included). These simplifications ignore the differences between racial groups, and even within nationalities and ethnicities within those racial subsets. Because of the Pew report, and as part of my focus on race-based health disparities and maternal child health, I decided to look further into the data on Asian Americans and Pacific Islanders.

What we do know is that API women suffer from higher rates of certain negative maternal and child health outcomes than their white counterparts.

Read the rest here.

Bellevue shuts down birth center for low-income women

Word got out a few weeks ago that Bellevue, a hospital in Manhattan (New York City) was shutting down their in-hospital birth center which was opened in 1998. It was the only birth center in Manhattan to accept Medicaid, and probably one of the few around the country serving low-income women.

From the NY Times:

The center gave healthy women the opportunity to give birth in a comfortable environment absent the frenetic bustle of a normal hospital delivery ward. Roughly 85 percent of the patients were Chinese- or Spanish-speaking immigrants, most of them referred though Gouverneur Healthcare Services on the Lower East Side. (All midwives were required to be fluent in either Mandarin or Spanish.)

The center allowed healthy expecting mothers to walk around, bathe in a Jacuzzi as a way to reduce pain naturally, and choose to forgo common but invasive medical techniques like induced labor and epidural blocks. Unlike women who chose natural birth at home, patients had immediate access to hospital facilities if there were complications.

Fans of the birth center said that it had a Caesarean rate of less than 4 percent over its lifetime; the hospital said that such a statistic was not available.

According to the NY Times, the closing was done secretively and without much notice to the public or even the hospital advisory board. While economics was cited as the reason for the closure, this flies in the face of the information about how the birth center reduced interventions (and cost) for women who delivered there.

I think this is just further proof that most hospitals don’t care that much about outcomes or patient satisfaction–they care about money. Rumor is that the birth center will be leased out for some other purpose (generating revenue via rent or the income of whatever facility they install).

Here’s the financial math that I think is insidious and behind this kind of decision:

While you would think it’s a good thing that these patients were having births that were much less expensive (because of lower interventions and c-sections), it actually means the hospital loses revenue. Why? Because they don’t have as much to bill Medicaid for, meaning less money for the hospital.

What does that mean? Our current system of health care (which is primarily profit driven) doesn’t result in the best care for women, or their children. It’s the same logic that has created our health care system which spends way more per capita than any other country in the world, but has relatively bad outcomes.

In 2002, the United States spent $5,267 per capita on health care—53 percent more than Switzerland, the next-highest-spending country, and 140 percent more than the median OECD country.

Want to try and get the Bellevue Birth Center back? Sign this petition by Choices in Childbirth.

One main cause of health disparities? Racism.

This is not surprising.

In 2004, black women were nearly four times as likely to die in childbirth as white women nationwide, and had a maternal death rate of 34.7 per 100,000 live births compared to 9.3 deaths per 100,000 live births for white women.

I’ve talked about maternal mortality before, and how the US is at the bottom of the rankings for the developing world. You also probably already know that women of color face disproportionately high rates of infant mortality, low birth weights and maternal mortality. This article discusses how a new set of reports called the Safe Motherhood reports try to delve deeper into understanding why these risk factors vary. There are the obvious ones we could come up with (no MPH degree necessary) like poverty, lack of access to prenatal care, stress and racism. But these studies are finding something more puzzling:

But one chart shows that black women with adequate prenatal care died at a rate comparable to that of white women with inadequate prenatal care — which hints at a medical mystery a small field of researchers are trying to explain. While some analysts emphasize a lack of health care and poverty to explain high maternal mortality rates among black women, newer studies have indicated that regardless of a black woman’s income and education levels, black women are more likely to die having a baby than white and Latina women.

When we discuss health disparities it’s super important to talk about RACISM. Why? Because a fact like that one above can easily lead to conclusions about the genetic predisposition to maternal mortality, for example. So instead of furthering delving into an understanding of how racism and poverty might affect these women (even if it’s not the poverty that they themselves are currently living under), one could argue that black women are simply predisposed to risk factors that can increase the risk of maternal mortality.

Similar arguments are being made about things like heart disease, or diabetes, for the Black community as well as Latinos. I think we need to be clear about what these health disparities tell us: that racism exists and has a serious and LASTING effect on the experiences of people of color. This effect is so powerful that not even improving ones class status via income or education can erase it. That’s one side of it. The other side of it is that even educated, wealthy women of color still experience the effects of racism on their health and wellbeing. And when I say racism, I don’t just mean prejudice between individual people. I also mean institutional racism, which establishes systems that favor certain racial groups over others. Like the prison industrial complex. Or the public education system. These things have an impact on the overall health of a community.

I could get into a whole diatribe (similar to ones I’ve gotten into around gender difference) about the social construction and lack of biological link to race difference. But I won’t, because I think overall we are beyond that. Doesn’t mean sometimes these things don’t sometimes need restating. To conclude: it’s important to study health disparities and race, so we can document where more work needs to be done. But the point is not to make essentializing statements about the differences between the races. Definitely not.

Note: the above article did a good job of talking about the social factors affecting this, I just used it as an opening to talk more about this issue.