Gathered in the parking lot of my hometown church, family and friends were “catching up” with each other before leaving the annual “Homecoming” service and dinner.

While in the parking lot, I overheard a conversation between two cousins. One was sharing that she had attended two funerals the day before, and her husband had been ill for several months. Caring for her husband, maintaining a full-time job outside the home, and responding to the needs of her adult children and grandchildren had taken their toll on her physically and emotionally.

She also commented that she was experiencing back pain but decided it was only arthritis. In this cultural context, arthritis is a minor, recurring and mostly annoying pain that is associated with aging. She had recently celebrated her 51st birthday. Her cousin asked if she had gone to see the doctor about the pain in her back, and she replied, “No, I just didn’t want to hear any more bad news.”

Back in Atlanta, I attended a high school basketball game and sat beside the uncle of one of the girls on the dance team that would perform at half time. He knew I worked at CDC and was curious about my work at the agency. I described our focus on eliminating health disparities, and this ultimately led to a conversation about a health issue he was having. He told me that for several months, he had been seeing blood in his stools. He was very concerned, and wondered if it might just be hemorrhoids. I asked if he had gone to see a doctor about this, and he said, “No, I just don’t want to hear any bad news.”

While conducting research several years ago with black men with type 2 diabetes, I was referred to a man who was experiencing multiple symptoms of diabetes but declined to be tested.

I asked why he didn’t want to know if he had diabetes, and his response was “it’s not a good time to know.” “Why isn’t it a good time?,” I asked, and he said, “I’m taking care of my elderly parents, the economy isn’t good, and it’s just not a good time to know.” I told him that if he in fact had diabetes, it was better to know and take action to control it. He didn’t say anything, but got into his car and drove off. I don’t know if or when he was ever tested for type 2 diabetes.

As a medical anthropologist, I am always interested in these types of arguably anecdotal statements made in unsuspecting community contexts to help explain why despite the progress our nation has made over the past 50 years, racial and ethnic minorities still lag behind the general population on many health fronts.

We know that communities of color are less likely to get the preventive care they need to stay healthy, are more likely to suffer from serious illnesses, such as diabetes, heart disease and colon cancer, and are less likely to have access to quality health care.

But now, because of the Affordable Care Act, preventive services, consumer protections, and other reforms under the Affordable Care Act are giving millions of Americans of all ages, races and ethnicities more value for their health care dollars and contributing to the slowest growth in health care costs in 50 years.

The Affordable Care Act is already making prevention more affordable and accessible for all Americans by requiring health plans to cover many preventive services for free. For example, new health plans must offer no-cost coverage for services that will prevent and control these diseases, like:

• Screening for obesity, and counseling from your doctor and other health professionals to promote sustained weight loss, including dietary counseling from your doctor.
• Blood pressure screening, and counseling on the use of daily aspirin to reduce the risk of a stroke.
• Tests to screen for high cholesterol and diabetes to reduce the chances of developing heart disease.

So how do we work together to ensure that more people actually use and benefit from these services?

Achieving the goals of the Affordable Care Act is a shared responsibility between health care and public health practitioners, policymakers, employers, and the community. A full discussion of strategies that can bridge the availability of services with persons needing those services is beyond the scope of this blog; however, there are places to begin, such as:

• Mobilizing state and local health departments, community-based organizations, voluntary health organizations, and other community resources to implement what has been learned through research and practice about patient activation and patient and family engagement to increase utilization of health services among people who have not previously had access and must now learn how to navigate the health care system;



• Engaging Community Health Workers and Patient Navigators;
• Ensuring a diverse and culturally competent workforce;
• Creating prevention messages that encourage the use of preventive services in ways that leave people feeling empowered by the decision to take advantage of these services rather than “not wanting to hear any more bad news.”
• Acknowledging and addressing the social determinants of health, and the disruptions that come when there is a diagnosis of a life-threatening disease (e.g., new demands on one’s time, attention, and finances; new uncertainties about the future; yet another thing to manage) among people whose lives are already stressed and vulnerable;
• “Reaching in” to communities of color and collectively working to change the community conversation to one that promotes wellness and believes we can prevent disease.

How will you implement and benefit from provisions in the Affordable Care Act to achieve healthier communities?

References:

1. Lasser, K.E.,Murillo, J., Lisboa S., et.al. Colorectal Cancer Screening among Ethnically Diverse, Low-Income Patients. Arch Intern Med. 2011; 171(10):906-912.
2. Carman, K.L., Dardess, P., Maurer, M., et.al. Patient and Family Engagement: A framework for understanding the elements and developing interventions and policies. Health Aff February 2013, vol 32(2):223-231.
3. Hibbard, J.H., Greene, J., Becker, E.R., et.al. Racial/ethnic disparities and consumer activation in health. Health Aff September 2008, vol 27(5):1442-1453.
4. Hibbard, J.H., Greene, J. What the evidence shows about patient activation: Better outcomes and care experiences; Fewer data on costs. Health Aff February 2013, vol 32(2):207-214.
5. Cooper, L.A., Powe, N.R. Disparities in patient experiences, health care processes, and outcomes: The role of patient-provider racial, ethnic, and language concordance. The Commonwealth Fund. July 2004.
6. Cleland, J.G.F., Ekman, I. Enlisting the help of the largest health care workforce – Patients. JAMA, September 22/29, 2010, vol 304(12):1383-1384.

It is customary at the end of each year to pause and celebrate achievements, ponder lessons learned, and renew commitments to do more, even better. Having marked our accomplishments, we look to the new year with anticipation and new aspirations. As we begin 2013, I want to reflect briefly on progress in the national agenda to improve minority health and reduce health disparities, share some shifts in our thinking, and greet the new year invigorated and ready for the opportunities and challenges ahead.

Since the publication of the 1985 Secretary’s Task Force Report on Black and Minority Health, the federal government has revised and renewed our efforts to reduce health disparities through the National Partnership for Action (NPA); the National Prevention Strategy; Healthy People 2020; and provisions in the Patient Protection and Affordable Care Act, to name a few. Along with increasing access to quality health care, these national initiatives represent a strategic revision in the national agenda to shift our attention from “excess deaths” highlighted in the 1985 report to the social and physical environments – broadly understood, that help shape health outcomes.

Last year, CDC’s Office of Minority Health and Health Equity established five priority goals, one of which is to “reframe eliminating health disparities as achievable.” In this reframing, we are exploring ways to modify and expand how health disparities have historically been documented, explained, and addressed. In the field of public health, minority health is principally examined through the lens of epidemiology – the study of the distribution and determinants of health-related states or events in specified populations. In the case of minority health, this study is primarily applied to the prevention and control of health problems. Descriptive epidemiological studies are sometimes reported as point-in-time snapshots and others reflect trends over time. What could be more fully described in reports of these studies are the historical events and social conditions that contextualize health outcomes.

For example, health disparities between African Americans and whites in the U.S. are well documented back to the 15th and 16th century slave trade of Africans in the U.S. and North America; continuing through different historical landmarks of the antebellum period of slavery in the South; the post-Civil War and Reconstruction eras; post-Reconstruction and the span of “Jim Crow,” and persisting through the Civil Rights era; and more recent “Black liberation” and “Black Power” movements of the late 1960’s and early 1970’s. [Source: Byrd, WM and Clayton, LA. An American Health Dilemma. (2000)]. Revisiting the history of minority populations in the U.S. and how these events impact health are important in our reflections, revisions, and renewals as we plan for the future.

Nationally and at CDC, there has been considerable progress over the past several years in attending to the social determinants of health. With this attention comes the necessity to work with data outside of the public health and health care domains (e.g., education, employment, social services); to champion innovative and rigorous surveillance and evaluation methods that capture the impact on health of programs addressing social determinants, regardless of the sector (e.g., health, housing, justice) in which programs reside; and to increase awareness within the larger population of the relationship between health outcomes and a host of social factors.

Moving forward, we will focus as much on reporting solutions as we do in describing the problem. We will work with partners to catalyze a dual strategy that mobilizes both affected community members and the institutions and sectors that shape opportunities for health. We will refine our understanding of minority health as distinct from conventional descriptions of the burden of disease experienced by minority communities.

As social norms are changing toward healthy living, we must be sensitive to those who feel guilt and frustration when they are not meeting the new cultural expectations such as maintaining an ideal body weight or prescribed exercise regimen. There are small successes such as having a blood pressure check or eating more fruits and vegetables we can and should celebrate. In the new year, we will consider how the language we use to talk about minority health may motivate or discourage people from caring for their own personal health.

As we begin the New Year, it is worth reiterating that health disparities are a societal issue and not just the burden of selected populations. In the years ahead, we must identify ways to quantify and communicate to all of our society the benefits to everyone in eliminating preventable health disparities and achieving health equity.

What are your reflections, revisions, and renewals to help eliminate health disparities in 2013?

A colleague and I were recently discussing “the good ole days” over lunch. We reminisced about the neighborhoods we grew up in, the influence of our families and friends, and how we dodged poverty, violence, and isolation. When I look back, my years in college were probably the most significant period of personal growth, hard work, and good times. I can also remember times of confusion and indecision—particularly as I struggled to declare a major. I had always been interested in a health career. During high school, I was exposed to physicians, nurses, physical therapists, and pharmacists, and decided I would become a physician. However, after receiving a C- in my freshman chemistry class, I knew the “pre-med” curriculum was not for me. During my junior year, I took a course in medical anthropology and was introduced to public health by my professor who was also a physician. I learned that “health” was determined by so much more than the provision of health care services. It was during my senior year in college that I decided to pursue a graduate degree in public health, and the rest (as they say) is history.

These are exciting and trying times for public health. Not unlike other sectors, we are expected to do more with less to overcome both longstanding and emerging health threats.

According to the Association of Schools of Public Health (ASPH), by 2020, the nation will be facing a shortfall of more than 250,000 public health workers. They further estimate that, over the coming decade, schools of public health would have to train three times the current number of graduates to meet projected needs.

Even though we live in a nation with the most technologically advanced health care system in the world, not all Americans are benefiting from these advances.

In light of the growing diversity of the U.S., we need a workforce trained to develop, implement, and evaluate public health policies and programs that accommodate differences in culture and health-related behaviors; to engage communities in the process of public health practice and research; and to pursue health equity. Language services are needed to assist persons with limited proficiency in English, and there are many who need help navigating the health care system. Health literacy, public health informatics, social media, and global collaborations to reduce health threats also contribute to eliminating health disparities and point to skills needed by the next generation of public health workers.

Last September (2011), our office launched the “National Undergraduate Summer Public Health Program” to contribute to the pipeline of public health workers. The goal of the program is to expose undergraduates interested in health disparities to public health as a career option. Over 2700 students from all over the country applied for 200 slots. At the end of an 8 week practicum in a public health setting, the students gathered at CDC to learn about the domestic and global work of the agency. Their energy, enthusiasm, and curiosity filled the hallways. They explored career options, and talked with CDC scientists about their pathways to public health.

They made friends and established connections with seasoned public health workers and researchers. All indications are that the majority of the students walked away from this summer public health experience energized and more informed about the difference they can make in public health and in eliminating health disparities.

Cesar Chavez –Mexican American farm worker, labor leader, and civil rights activist– once said, “We cannot seek achievement for ourselves and forget about progress and prosperity for our community… Our ambitions must be broad enough to include the aspirations and needs of others, for their sakes and for our own.” What else can we do to ensure a generation of public health workers with the skills needed to end health disparities?

This summer, my nephew was killed while riding his motorcycle. He was just 2 months shy of his 41st birthday. I can still hear my daughter saying “I have some really bad news…Junior died.” The crash happened at night. He was hit by a car turning left into the entrance of an apartment complex, and although my nephew had the right of way, the driver said she “didn’t see him.” He was wearing a helmet and driving within the speed limit. According to a recent CDC study, between 2001 and 2008, more than 34,000 motorcyclists were killed, and there was a 55% increase in motorcyclist death rates during this period. More people in the U.S. are riding motorcycles today than ever before, making motorcyclist deaths and injuries an important public health concern.

Interestingly, I didn’t know that Junior (as we called him) rode a motorcycle or was in a motorcycle club.  At the funeral, I would get a glimpse into the culture and perspectives of his community of motorcyclists and the camaraderie they shared. 

There were easily 200 bikers in a motorcade to the center where the service was held.  Young men and women gathered to pay their respects.  Two men arrived in wheelchairs proudly wearing their leather vests designating them as members of the club, while another young man wore a tee-shirt with the word “Probie” written across it (identifying him as being in the training or initiation phase for membership in the motorcycle club).

The leaders of the club had names like Matrix, Scarr, Iceman, and Heavy. My nephew was known as “Prince Z.” [1] 

The service was at once sad and celebratory. People spoke of his love of the “rides,” the cool way he walked, his love of New York City, and the way he referred to the men as “son.”  We were told that he wanted to join the motorcycle club because it was a place where “men act like men.”

During the week preceding my nephew’s funeral, 6 motorcyclists in his social network had been killed.  Even without knowing how many motorcyclists there were in his social network, 6 lives lost in one week due to motorcycle crashes seems like a lot to me. 

According to a study by researchers at Johns Hopkins University, despite the fact that black Americans are more likely to wear a helmet when they get into a motorcycle crash, they are 1.5 times more likely to die from their injuries than white Americans.

The reasons for this disparity are unclear, but the researchers suggest that contributing factors include lack of health

insurance, less access to care, poorer quality of care, and having a greater number of pre-existing illnesses or injuries.  

They also note differences in the types of helmets and/or motorcycles that black riders prefer. [2]

What might we learn from motorcycle clubs like this one about how to better protect bikers?  What injury prevention strategies could we share with them?

[1] These are pseudonyms to protect the identities of the motorcycle club members.

[2] Racial disparities in motorcycle-related mortality: an analysis of the National Trauma Data Bank  The American Journal of Surgery, Volume 200, Issue 2, Pages 191-196.  Joseph G. Crompton, Keshia M. Pollack, Tolulope Oyetunji, David C. Chang, David T. Efron, Elliott R. Haut, Edward E. Cornwell, Adil H. Haider”.

In this blog I argue that a culture of silence continues to exist in some communities, and that silence can be a risk factor for health disparities. In deference to scholars like Paulo Freire who have more fully and theoretically described the existence of a “culture of silence,” my purpose is more practical and interpersonal in that I want to spark a conversation about ways silence can undermine important health decisions and enable preventable health disparities. I conclude with the idea that giving voice to issues that have been silenced and related to health outcomes might contribute to reducing and eliminating health disparities.

A risk factor is a characteristic, condition, or behavior that increases the possibility of disease or injury; a factor that causes a person or a group of people to be particularly susceptible to an unwanted, unpleasant, or unhealthful event; and, any factor, based on epidemiological research, known to be linked to a particular disease—e.g., smoking and lung cancer; red meat and colorectal cancer; sedentary lifestyle and heart disease. Silence – experienced as quietness; as a refusal or inability to mention, comment or express a concern about an issue; as concealment and/or secrecy – is a form of communication and likely present in all cultures. Meanings ascribed to silence do vary by context, culture and cultural groups. From the health standpoint, periods of silence and solitude can be physically and mentally invigorating particularly given the noise and demands of contemporary lifestyles. For example, positive health benefits have been associated with meditation. This silence is encouraged. However, silence is problematic when it contributes to a culture that perpetuates misunderstanding, inaction or avoidance of issues that impact the community’s health.

For example, African Americans are the racial/ethnic group most affected by HIV. Most (85%) of African American women with HIV acquired it through heterosexual sex. Removing the silence that inhibits real talk about the attitudes, beliefs, and practices that enable this epidemic, coupled with the policies intending to increase access to HIV screening and treatment, can reduce this disparity. Being obese is a stigmatized condition in the U.S. Uncounted women of color are struggling to be healthy (physically and mentally) while trying to survive and thrive in stressful professional, social and economic environments. They are silent about their struggles – lest they be viewed as not up to the tasks before them – even though it is vital for them to share the challenges they face in order to overcome them.

Let’s talk to each other about our weight, activity patterns, and dietary practices in public and private spaces with empowering information and testimonials. Let’s create a space in private and in public to talk about intimate partner violence, the truth about our relationships, and what we need in order to experience quality life and good health. Be open to discuss, interrogate, and understand difference in the human experience. There is power and freedom in knowing when to be silent and when silence is a risk factor for poor health and health disparities. What conversations are you not having that could help eliminate health disparities and improve your own health?

As part of the celebration of this year’s National Public Health Week, I was invited to participate in a day of events sponsored by the College of Health and Human Services at the University of North Carolina, Charlotte (UNCC). We began the day with Charlotte Talks – a local radio talk show – discussing the role of prevention and access to health care in reducing health disparities. I was joined by Dr. Crystal Piper (UNCC) and Mr. Brad Wilson, CEO of Blue Cross and Blue Shield of North Carolina for the interview with Mike Collins, host of Charlotte Talks. For an hour, we engaged in a rich dialogue and debate about issues ranging from personal responsibility for health, poverty and other determinants of health, to the benefits, challenges, and costs associated with insuring access to health care for all. We were kindred spirits and like minds sharing the microphone –understanding what can be accomplished when public health and medicine join forces to reduce health disparities.  However, the questions and rebuttals from Mr. Collins and his listening audience reminded me again that we must continue to host these conversations in communities, come with examples that people can relate to now, and not shy away from the hard questions that begin with Why? and How?

Some examples of what we heard during the radio talk show include several thought provoking challenges.

“Racial and ethnic health disparities are not new, so why do we think we can change these trends now? How do we personalize the prevention message such that people (of color) see themselves actually doing and benefiting from primary prevention?”

There is a growing awareness that low-income communities and communities of color tend to lack easy access to health-enhancing resources such as healthy foods, high performing schools, employment, and healthy housing, but how do we change this social landscape? These are important ‘close to home’ questions that should guide the planning and content of our outreach and public education efforts.

How do we incentivize prevention within the health care system? Blue Cross and Blue Shield of North Carolina, for example, is working with communities across the state to develop innovative strategies that support clinical and community preventive services –one of four cross-cutting themes of the National Prevention Strategy. Blue Cross and Blue Shield of N.C. is also promoting community gardens and greater use of community health workers in its outreach efforts.

Considerable knowledge and experience have been gained over the past 2 decades demonstrating that health disparities can be eliminated through well designed, adequately implemented, community-focused and community-engaged strategies. The CDC website is one source for national data, and evidence-based programs that can be disseminated and replicated in demographically similar communities. There are others including, but not limited to, HHS, OMH Resource Center, Place Matters, the Diversity Data Project, and the National Diabetes Education Program.

Even as we push out our prevention messages through a variety of channels, and promote the implementation of policy and environmental changes that make the healthy choice the easy choice, there will be those who remain skeptical that people will adopt the healthy lifestyles we espouse. Let’s not be swayed or disheartened by the magnitude of the goal –moving the nation from a focus on sickness and disease to one based on prevention and wellness. We in public health can and will move from skepticism to expectation –the expectation being the attainment of the highest level of health for all.

Welcome to CDC OMHHE’s New Blog: Conversations In Equity! In this 1st Blog Post, Dr. Leandris C. Liburd, Director of CDC’s Office of Minority Health & Health Equity (OMHHE) explains what she does.

Leandris C. Liburd, PhD, MPH, MA, Director, CDC OMHHE

An awkward pause often precedes my response to the question “So, what do you do?” Describing in plain language what we do to address health disparities and reduce the high burden of preventable disease and premature death experienced by communities of color and other population groups is rarely a quick response.

Helping people understand why these disparities persist, sharing effective public health approaches for reducing this burden, and showing how what we do in CDC’s Office of Minority Health and Health Equity (OMHHE) ultimately impacts health outcomes in communities is often challenging and never achieved in the time it takes an elevator door to close.

The Centers for Disease Control and Prevention (CDC) first established our Office of Minority Health in 1988 through the advocacy of minority scientists and public health practitioners and the support of then agency director, Dr. James Mason.  Since its inception, our office has championed a number of initiatives and collaborations that have helped to institutionalize a focus on minority health, eliminating health disparities, and more recently, achieving health equity.

Our mission –to accelerate the work of CDC and our partners in improving health by eliminating health disparities, promoting conditions conducive to health, and achieving health equity– is long-term, cross-cutting, and dynamic. I, along with my colleagues in OMHHE, maintain a strong conviction that there is no more important component of public health than eliminating preventable health disparities and pursuing health equity.

We work closely with CDC’s national centers, institutes and offices to:

1. Promote the dissemination and scaling up of evidence-based interventions and other population-based strategies that reduce and eliminate health disparities,

2. Advance the science and practice of health equity,

3. Build national and global partnerships to address health inequalities, and

4. Ensure federal policy initiatives in support of health equity, such as Healthy People 2020, the National Partnership for Action, and the National Prevention Strategy, are integrated into CDC programs.

So, why the pause when I start to talk about what I do? Well, people who live in communities with a high burden of disease see and experience every day what we take great care to describe in our surveillance reports. So, I don’t need to talk about the burden with them. There are others who don’t live in these communities, who aren’t aware of health disparities, who become interested in these problems and their root causes once we’ve had a dialogue.

There is sometimes a real disconnect between the prevention work of public health and the day-to-day experiences of ordinary people. In other words, a good day in public health is when the spread of any disease or risk factor is prevented; and people typically don’t recognize or necessarily value something that never happened. Imagine our efforts in communities being so successful that health equity is the norm! It will take all of us working together to make this a reality. What are you willing to do?

This Blog entry is Cross Posted on the HHS OMH NPA Blog