Basic Black; 3916; Black Health Checkup: A Conversation With Mass. Secretary of Health JudyAnn Bigby

You The state of health for Massachusetts communities of color coming up on basic black Eliminating racial and ethnic health disparities in Massachusetts has been a top

priority of the Patrick administration To that end, Department of Public Health recently released a report covering a broad spectrum of health issues confronting these communities I'm Kim McLaren and I'm pleased to be joined by Dr. Judy Ann Bigby, Secretary of the Office of Health and Human Services To discuss their findings. Dr. Bigby, welcome to Basic Black. Thank you very much for having me. It's great to have you here. Let's talk about this report for beginners. What surprised you most or struck you among the findings of this report? Well, I think the thing that I was most surprised by, even though I've been working on this issue for more than 20 years, is the breadth of disparities across the Commonwealth Previous to joining Governor Patrick and his administration, I worked mostly on health issues in Boston and I think everybody is well aware of the disparities that exist in cities like Boston But when I asked for the Department of Public Health to pull this report

together and to make sure we looked at all the regions in the Commonwealth I was struck that disparities exist everywhere. There's no place in the Commonwealth of Massachusetts where we don't see racial and ethnic health disparities So what were some of these geographic differences then? they exist not only in the urban areas but also in the rural and suburban areas? That's correct. So basically the report divides Massachusetts into several regions including the greater Boston area but also the northeast, the southeast, central Massachusetts and western Massachusetts And what you see are disparities and just about all indicators. There are some differences that are regional however. So for example, in western Massachusetts one of the biggest disparities we see is the rate of teenage pregnancy among Hispanic young adult women Teenagers, which is the highest of anywhere in the state,

but we also see consistent patterns. Diabetes prevalence is higher among Hispanic and Blacks in all regions of Massachusetts We see HIV, AIDS, but then in other areas we see that the cancer rates might be different in some racial groups compared to others depending on the region of Massachusetts But as I said the most surprising thing to me is that we see these disparities across the state So how do we begin to make sense of these disparities, not only racial but also geographic? If I understand you're saying that the racial disparities persist across the state but in some areas they might be different How do we begin to make sense of this? Well I think that one of the good things about the report is that we can give communities data so that when they're thinking about what do we need to do to make our communities healthier and our part of the state they actually have something to start with So they can look at the report and

decide to prioritize, for example, on particular issues. So teenage pregnancy might be something that the people in western Massachusetts who we're working with might choose to prioritize So I think that one of the things that's helpful about the report is that it does allow communities to see where they stand and to understand where it might most benefit their communities and target their resources I think that the other thing it helps to do is to identify for both the Department of Public Health but also public health entities around the state to sort of look at what are the basic issues here that we really need to pay attention to So if we look at diabetes and see that it's more prevalent in some populations than others we shouldn't just be thinking about how do we treat diabetes in those communities We should be asking questions like are these communities

where kids and adults have safe places to do physical activity on a regular basis? Are there affordable, nutritious foods, fruits and vegetables in these communities? It helps us to really think about the whole picture of disparities and the things that contribute to A broader spectrum. So you look at preventive issues. I wanted to ask about the correlation between health disparities, racial health disparities and social economic status Because of course a lot of people say this is not necessarily about race as it is about class which implies access to care, all these kind of issues So what does the report say about that and what are your thoughts about that? Well this is a common issue that people bring up who can't quite understand why we would have racial and ethnic disparities in a country, in a state that has one of the best healthcare systems in the world What we know is that

this is not a socioeconomic factor. While it is true that people who are poor tend to have poorer health than people who are better off in terms of financial situation And that the least educated among our populations tend to have poorer health status This does not account for the differences in health among black individuals or in some cases Hispanic individuals which are the two populations where we see the biggest disparities So for example if you look at the infant mortality rate in Massachusetts, black women with a college education will have higher rates of low birth weight babies and worse infant mortality outcomes than white women with With equal education for sure but even with less education So while those black women who do have a college

degree have better outcomes than black women who don't have a high school diploma for example, they don't do as well as white women with the same level of education or opportunity So it is not purely a socioeconomic issue. We also know that it's not just an issue about access to care If you look at any number of studies that take into account whether people have health insurance, we find that with equal types of insurance and people are accessing the healthcare system, they don't get the same quality of care I saw one study about black women and I believe it was heart catheterization and even when you held accountable, held steady for act for health insurance and income, they still had a worse outcome So how do you begin to get organizations, medical facilities, hospitals to take responsibility for these

disparities? I think that the way that we can do that is to actually continue to monitor the type of care that is given So in January of 2007, Massachusetts actually started collecting data on hospital information, people who are discharged from the hospital by race and ethnicity And there is a regulation that requires all hospitals in the state to collect this data in a uniform way So for the first time, we really have the opportunity to have accurate information about people's race and ethnicity based on what they declare themselves to be Not somebody kind of looking at them and writing something in their chart So one of the ways that we can use those data are to continue to report back to hospitals Are you delivering the same quality of care to people

if we divide things up by race and ethnicity? If we have expectations about the type of treatment that people with pneumonia or heart attacks should get, if we look at subgroups, are they getting equal treatment? And I think that how institutions, how hospitals or doctors decide to fix the disparities they see, they're going to have to work within their institutions to develop the best strategies But we can continue to monitor whether those things are working by continuing to look at whether or not the disparities exist So you begin by holding a mirror up to them and then the question becomes, what is their responsibility? mean, is it given if they have different populations and different subsets, what is the responsibility of the organization towards the health care of its clients? I think they're totally responsible. They

are clearly responsible for delivering the best care of the highest quality to people who they take into their system and provide care to But can you measure that by outcome, I guess, is the question? I think you can. There are ways that we look at the steps to the best health outcomes So, for example, one of the areas where there is shown to be significant disparities is the type of diabetes care that individuals with diabetes get We know that people with diabetes need to have aggressive management of their high blood pressure They need to receive medication to make sure their cholesterol levels are low And another example is they need to have an eye exam every year to make sure they don't develop blindness from their diabetes When we look at individuals, again, who have the same health insurance, they're going to their doctor We see that those types

of indicators of good care are lower in black people than they are in whites So what is the role of the state and what's the role of the individual in this, in demanding that these institutions, these physicians, these hospitals provide the kind of quality care across the board that you're talking about Where does the state come in and where does the individual come in? Well, I think that the state can hold individual providers accountable by one of the things that we're doing in Massachusetts That is part of the health care reform law The law requires the Health Care Quality and Cost Counsel, which is a new entity, to actually put information about quality of care on a website so that people can go and see what type of care compare I have the goal of, at some point, we should be able to look at those type of data And if we are collecting race and ethnicity, which we

are, we should be able to make a statement about whether or not people are getting equal care I think that the other thing the state can do is to make sure we bring people together and have a conversation about what are the best practices toward eliminating health disparities and make sure that people are learning from successes and that individual providers or institutions who are developing programs or implementing programs that are successful in addressing disparities that we get the word out and use them as models That's one of the things, last year we, the Department of Public Health, awarded a million dollars in grants across the state to address health disparities and one of the things that we are doing is to examine what kinds of programs came out of that grant effort and we'll be able to describe what seems to be

successful Okay, great. I want to switch gears a little bit here and talk about the issue of violent crime and how that impacts health care and health issues especially for communities of color. What's the correlation there in the greater Boston area across Massachusetts and does that have an impact? Obviously it does, but what is the impact and how do we begin to address that? Well, I think that people obviously are concerned about violence in communities for the violence itself I think that what people are unaware of is the impact it has on all of the community Well, there are several ways. Number one, the stress of living in communities where people feel unsafe is one of the factors that we see that's correlated with poor birth outcomes, for example So women who live in communities where there

is a certain level of violence are more likely to have premature babies and have low birth weight babies even if they themselves have not been involved directly with the violence We know the children who live in communities where there is violence are less likely to participate in activities that can prevent obesity Because it's simply not safe for them to be outside playing, so these people have this ripple effect Exactly, so their activity is they stay inside and play computer games or watch television or whatever The other thing that we're learning more and more about is that this whole issue of having a high stress level impacts people in terms of having a higher episode of high blood pressure It increases people's risk for diabetes and for being overweight because they have a constant level of stress hormones that are elevated above normal and you know

in most people when you're stressed your hormones go up and when you become less stressed they go down and that's normal, that's what we expect to happen but when you're constantly under stress you have this altered pattern of the level of stress hormones and it can be bad for your health Okay, so that's interesting, there are all these impacts that we don't necessarily think about You mentioned low birth weight, you've mentioned that several times and I want to talk about the health care challenges facing the two ends of the human life spectrum You've talked a little bit about infant mortality, what other challenges are facing Massachusetts infants and then what are the challenges health care wise facing our elderly population because we have a significant elderly population too So let's start with infants, you talked about infant mortality Once the child is here what are the challenges facing especially infants of color in Massachusetts Well, so the infant mortality rate is almost three times higher among black babies than it is for white babies in

Massachusetts and this has been a long standing problem and what that means is that a black baby born in Massachusetts is almost three times more likely to die before his or her first birthday Three times more likely than a white baby And that is a marker of health in the society, it's a worldwide marker that's used and so it's something that we pay a lot of attention to The causes of infant mortality range from birth defects to other things but the biggest reason that babies don't survive their first birthday is because they're born too early and at a low birth weight So our goal is to figure out why that happens We have done a good job actually of being able to take care of babies who are born at a low birth weight and premature over the last

20 years If you look at infant mortality since neonatal intensive care units came into effect the infant mortality rate has gone down but at some point we're just not seeing that gap go away completely and that's because there's a limit to how much technology and health intervention for low birth weight premature babies can have an effect So the infant mortality rate in general has dropped but the gap between black babies and white babies has remained Is that what you're saying? That's correct, that's absolutely correct And then for communities of color for our elderly population, what are the challenges facing us there? Well first of all, the life expectancy for black men is the lowest of any group both in the commonwealth and in the country And that's an issue that continues to persist

There have been times in the recent past where actually the life expectancy for black men was getting worse instead of getting better Which is what normally happens, yes Is that still true right now? That's not true right now but we see that black men do not live as long as either white women or black women or white men because they're dying from things that are preventable heart disease, cancer, HIV, AIDS, homicide is one of the factors that contribute to premature deaths So there's a lot that we need to do there Other issues for elderly people, even though people are living longer, they're living with chronic illnesses which are disabling And so we have a lot of disability among our elderly population And they don't always get the resources and the social supports that they need to live in the community in a way that allows them

to enjoy life when they should be Maybe we can switch gears again and talk a little bit about you You're the first in your family to become a physician That's correct And in fact the first to go to college, is that true? Well in my family that's true My brother who is older and I have a younger sister, the three of us were the first in our family to go to college What propelled you into medicine? What was the impetus there? Well I decided at a very young age that I wanted to be a physician I don't think I was older than about eight years old when that was the declaration that I made When I think back about why I said that, it's still a little bit of a mystery to me I often joke with medical students and other aspiring doctors from communities of color that my role models were three white men Marcus Welby, Ben Casey and Dr. Kildare Because those were

TV shows at the time that showed physicians And I was really intrigued by them I didn't have a family doctor myself And I do believe that that was sort of my exposure and my entree to thinking about the fact that I wanted to be a doctor Okay, alright And transitioning from that back to the larger question of health care in the African -American community What role do cultural issues play? What someone might call cultural competence I mean, our responsibility for taking responsibility for our own health And also comfort with medical care, trust in doctors I know that's an issue with my own family, my mother What role does that play in these issues, these health disparities? Well, that's a great question I think that what we have learned about the whole issue of cultural competence is that The issues that really are

underlying health disparities are not necessarily that there's this big divide in culture You know, as I have pointed out Black Americans have the greatest disparities in health of any population in the United States Except for maybe American Indians People who speak English, who grew up here, who know the culture So characterizing this as a cultural issue is a little bit of a stretch for me What I do think is a problem though is that there is this sense of mistrust And communication is a huge issue Not because people don't speak the same language But because the meanings are different to people And what about from the other side? What about the cultural expectations of the physicians or the doctors Even when they themselves are people of color I remember reading a story in the Boston Globe about health emergency room physicians Even when they were black giving

different care to black patients So where does that come in? Yeah, I think medicine itself has its own culture I think that oftentimes the way that health care providers interact with different people is based on stereotypes I think that the whole issue of not having enough time to spend with patients Is one of the biggest barriers to delivering culturally competent care Some of the issues though that health care providers have of different populations I'll go back to diabetes again There is the expectation that people will exercise and eat right But if they have no knowledge of the fact that there is not a grocery store in the neighborhood Or if there is a grocery store that the fruits and vegetables in Roxbury actually costs more Than the same food and the same chain in West Roxbury Then

people can't necessarily afford it And they don't have the opportunity to get in the car And just go to a supermarket that's further away just because they have better prices I think those types of differences are not well known always I want to get in a question about the state mandated health care insurance What impact is that? Are we seeing so far on health disparities from that? Well, it's a little bit hard to know because we're still early in the game Remember the law was passed less than two years ago And the implementation just started a little bit over a year ago One of the things that I can say that we're seeing is that there are 300 ,000 people Who did not have health insurance before health care reform who now have insurance Many of those people are low income individuals And one of the things that I look forward to is having a sense of how good our outreach

has been About getting people of color into these programs We did have higher rates of uninsuredness among blacks and Hispanics before health care reform started And so what I am hoping that we'll see as soon as we can collect new data Which won't be until this fall is that we'll see that gap begin to narrow And that will make a difference Our last question, real quick What's the main thing you hope to accomplish in your tenure as Health and Human Services Director? I think that what I would like to see is that there are 17 agencies in my secretariat I want them all to get to the point where we're providing the best that we can absolutely do For everyone who walks through the door Dr. Bigby, I'm sorry, but we're going to have to leave it there So fascinating, thank you so much for discussing health care issues in Massachusetts with us today Thank you for having me For the Basic Black team, I'm Kim McLaren Thank you for joining us

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