Reflections on Achieving Equity in Health and Medicine, 2023
Herman Taylor, Jr., MD, MPH
Endowed Professor and Institute Director
Morehouse School of Medicine
Adjunct Professor, Harvard Chan School of Public Health
Director, Morehouse-Emory Cardiovascular Center for Health Equity
21st Century Precision Medicine
Health Equity
---National Institutes of Health
“…is when every person has a fair and just opportunity to attain their full health potential…”
Health Disparities
• “…African American individuals… have a 2-3 fold increase in ..risk of developing clinically manifest CVD…”
• “..even after adjusting for relevant potentially confounding variables…”
• .... the relative risk of admission to a high-mortality hospital after adjusting for [relevant covariates]... in the logistic regression models an indicator variable for black race, was statistically significant...
• “Black Americans are twice as likely to experience a stroke...”
Imprecision and Inequity and the “American Problem”
(Hoffman, Publications of the American Economic Association, 1896)
Frederick Hoffman, a noted statistician who asserted the association of tobacco and lung cancer -- 70 years before the Surgeon General’s report
. . . gradual extinction of the race [will] take place.”
“Only by means of a thorough analysis of all the data that make up the history of the colored race in this country can the true nature of the so-called ‘Negro problem’ be understood….”
A more rigorous understanding
The Philadelphia Negro, Chapter X, page 148
“…One thing we must of course expect to find, and that is a much higher death rate at present among Negroes than among whites … They have in the past lived under vastly different conditions and they still live under different conditions…”
W.E.B. Dubois, 1899
Race is not “The Problem”…
Racism Is.
Racism: A Dominant Feature of the Exposome 1619- 2023
8
Discrimination and Hypertension
Racism:
“ … a system of power that structures opportunity (education, housing, jobs, justice)
and assigns value
(worthy or unworthy, full of potential or full of menace) based on so-called “race”, the social interpretation of how we look
Camara Jones, MD, PhD
.” -
Social Determinants of Health
• Socioeconomic status
• Education, occupation, job security
• Housing, clean water, food access
• Neighborhood safety, violence
• Social cohesion and community support
Clinical care accounts for only 10% of health status in the U.S.
S o u r c e : S c h r o e d e r, S A , N E n g l J M e d 2 0 0 7 ; 3 5 7 : 1 2 2 18
Impact of a single social determinant of health: Education
Essential Workers
African Americans are
• almost 30% of bus drivers
And a disproportionately large percentage of
• food service workers
• janitors
• cashiers
• stockers
• medical assistants, elder care nursing assistants, etc
These “essential” and “frontline” workforces are unable to work from home and tend to kids, making them exposed to the virus more than others
“ I have to go in.”
“When the Bough Breaks…”
“…predominantly black communities have fewer primary care doctors than predominantly white communities; black patients are more likely than white patients to receive care in inpatient and emergency department settings, rather than outpatient settings; and a larger fraction of visits for primary care by black patients are to physicians with whom the patients do not have an established relationship.
Bach et al, N Engl J Med
2004
”
An assessment of disparities near the turn of the 21st Century
data highlighted…
Need for more
How do we achieve the Vision of Precision?
● Data ● Analysis ● Response
How do we achieve the Vision of Precision?
● Data ● Analysis ● Response
In whom do you trust?
“There was never a time that I could not, at any day, have had a subject for operation.”
J. Marion Sims, MD
(“Father of Modern Gynecology(sic))”
Lack
Back BtC Initiative 20
of genomic diversity affects biomedical research, health predictions and outcomes
medicine
…and dims the prospects of precision
Steps toward precision…
The Jackson Heart Study
Health
Resilience:
maintenance in the face of risk
Understanding the environmental and individual promoters of CV health in this population may yield insights into the nature of physiological resilience
“The Harlem Ghetto” in Notes of a Native Son
(emphasis added)
“… the wonder is not that so many are ruined, but that so many survive.”
James Baldwin, 1955
MoyoHealth Network Mom
How do we achieve the Vision of Precision?
● Data ● Analysis ● Response
Training Program Fellows
Kia Jones, PhD
Jeong Hwan Kim, MD Matt Topel, MD, MSCR
Shakeira Cohen, PhD
Talani Wahington-Plaskett, MD Shabatun Islam, MD
Training Program Fellows: MECA and Multiomics
Emerging Center of Genomics Excellence
A training and outreach program to enhance the training and research opportunities of graduate students, post-docs, and faculty in genomics techniques and analysis approaches
A Multi-omics research project to generate data for graduate training (PhD) programs and to advance our understanding of how combining facets of multi-omic data and social determinants of health data can enhance our knowledge of chronic disorders.
Artificial Intelligence/ Machine Learning Consortium to Advance Health Equity and
NIH program seeks to increase the participation and engagement of the researchers and communities that are currently underrepresented in AI/ML modeling and applications through mutually beneficial partnerships.
How do we achieve the Vision of Precision?
● Data ● Analysis ● Response
Structural Barriers to Access
A Leaky Pipeline to the Profession
59% AA males high school graduation rate (2012-2013 school year)
Schott Foundation Report
33% college enrollment rate for AA males (2017)
While 1 in 8 Americans are African American, 1 in 24 doctors are; 1 in 6 Americans identify as Hispanic/Latino compared to 1 in 22 doctors
Steps Towards Equity…
42 have attended medical or dental school
175 scholars have completed the program
96 have attended graduate or other professional schools
35 have earned an MPH
5 have earned the JD
22 have earned the PhD
31
We must respond…
(Schulman et al., 1999)
without
People
“Precision” is not Precise
Precision: An Enduring Quest
21st Century Precision Medicine
Precision: An Enduring Quest