Transcription
Good morning, everybody. Thank you for being with us today, uh, and thanks for those of you who have joined us in person at Berg Hall. It was about 19 months ago we last came here for medical grand rounds, so we're really happy to provide this as an opportunity to come in person. No surprise, we expected most people to stay on Zoom. And I just want to mention that no matter what phase we are throughout this pandemic, post-pandemic, our goal is to always make sure it's a fluid experience for those of you who want to stay on Zoom or want to come in person when we have these in-person events. So we'll periodically have in-person grand rounds, but we'll always have the Zoom component so that you have that option going along. Always CME will always be the same, essentially. The experience hopefully will be as close as possible, the same as possible, but you'll certainly be able to get CME and so on.
We have a great speaker today, Dr. Maldonado. It's a special day; it particularly, I think, I think of as a special day for me as well because 19 months ago Dr. Malnotto was one of the key people who was in grand rounds here when we were all trying to figure out what was going on with the virus, and she had a lot of very important things to say. And since then, she's continued to have a lot of very important things to say and authority in many ways. We have her with us today, so we're really honored to have her speaking today.
One of the other things we're also celebrating, uh, this week, this month, is Latinx Heritage Month. Uh, Dr. Dunn had put together a few slides for us; she couldn't be here today. She was also, by the way, I would acknowledge her for helping organize this event today. So thanks, Dr. Dunn, uh, for doing that. I'm going to ask Dr. Harmon to comment on some of these things as well, a couple other slides. Dr. Harm, thanks so much.
Dr. Ostalga: Good morning. Um, to, to mark, um, Hispanic Heritage, Latinx Heritage Month, um, our upcoming grand rounds include Dr. Benicio De Jesus Perez, um, who is one of our own associate professors of medicine here. Um, next slide, please. I'm sorry, hybrid live. Um, the next event I wanted to announce was our inclusion rounds. This month will be a very special event with Dr. Rafael Campo, physician and poet at Harvard Medical School, who'll be joining us for both poetry readings and conversation. And that will be on October 21st at noon, and there will be a registration link that you'll get in a kind of a follow-up email after grand rounds. Next slide.
The last event that I wanted to mark was the Diversity Week for Stanford Medicine. This is in particularly aligning with the GME, graduate medical education, kind of season and basically bringing in, uh, different events all week alongside our GME colleagues. So stay tuned for more additional information as well in a follow-up email. Lastly, I wanted to announce a celebration of life for our own Dr. Brooke Gabster. This will be taking place this Saturday, October 9th, at 11 a.m., Memorial Church here on campus. I wanted to just make sure that you note to arrive a little early to provide for kind of COVID procedures, and there will be a live stream available at www.brookgabster.com, and that information is going to be also in a follow-up email as well. Thanks. Over to Dr. Harrington now.
Well, it's—thanks, Errol. It's certainly, uh, nice to be here in Berg Hall. It's been a terrific way to be able to share our medical grand rounds over the course of the pandemic through, uh, through the virtual modality. And I, I cannot thank Errol enough for, uh, for all the work that he's done to keep communicating with, uh, with our large department of medicine, uh, community. So thank, thank you, Errol. Your work has truly been, uh, heroic. I have two jobs today, one of which is to, uh, to celebrate a little bit and to congratulate and, uh, and the second is to introduce our, uh, our grand rounds speaker. For the celebration, the department of medicine is extraordinarily proud to, uh, to congratulate Kathy Garzio, our vice chair for finance and administration. We're even getting applause here in Berg Hall. That's, uh, that's been a long time coming. Those of you on the screen, please do give us your virtual applause. Uh, let me just read what the Blue Amy Blue Awards are. So for those of you who are not familiar with it, this is a Stanford University-wide, uh, award which honors staff who are quote exceptionally dedicated, supportive of colleagues, and passionate about their work. And I can think of no person in our department that those words described better than Kathy. She's made us a better department since the moment she arrived; she continues to strive to make us a better apartment, department. And I'd urge all of you to read the write-up about Kathy and her journey from the time she came to Stanford as an undergraduate through today and the many comments from her colleagues within the department. So congratulations, Kathy. We're very proud to have you in the department, and thank you for everything you do for us.
Next, I have the opportunity to introduce my good friend and colleague, Dr. Bonnie Maldonado. Bonnie is, uh, not a stranger to this medical grand rounds community because she's with us almost every week participating with updates, etc. But I want to take a moment to just reflect on how fortunate we are to have Dr. Maldonado in our midst. She is a graduate of UCLA and then started her lifelong journey at Stanford Medicine as a medical student. She did her internship in pediatrics here. She moved east for a bit to be a resident of fellow in pediatrics and pediatric infectious disease at Johns Hopkins University in Baltimore. She then spent time at the CDC and sort of, I think, foreshadowing what her life was going to become these last 19 months as she served as an epidemic intelligence service officer for the CDC. She returned as an assistant professor of pediatrics, has, has moved up the academic ranks to be a professor of pediatrics. She also is a professor in health research and policy. She has certainly done extraordinary work the last 19 months, but she's not a stranger to this business of viruses, epidemics, in fact, pandemics. If you look, which I've had the opportunity to do in the last day, at her biographical sketch for the NIH, the very first sentence says that her interests are in epidemiology, diagnosis, and prevention of viral infections. And in fact, she is truly one of the world's experts on the topic that has, uh, plagued us over the course of the last 19, 20 months as a global community. I can't imagine a person who's offered more to our community than Dr. Maldonado. And Bonnie, we're incredibly grateful for your talent, for your hard work, for your dedication to, to the public health. She wears another hat here at Stanford, which is an important one in terms of today's conversation; she's the senior associate dean for the Office of Faculty Development and Diversity, a role she's held since 2014. In the department, we are committed to the notions of equity, diversity, inclusiveness, and it really is with the leadership of people like Bonnie that we're able to do some of the things we do in the department of medicine. So thank you in that regard as well, Bonnie. Bonnie's going to combine her two interests into today's talk and really help us understand the social determinants of health and how those social determinants of health have really played out during the course of the COVID pandemic. So thank you, Dr. Molina, for joining us. [Applause]
Thanks so much, Bob, and I really, really take this opportunity to thank all of you in the department of medicine for your—um, and I have to figure out how to change my slide. Oh, got it. Okay, sorry. Perfect. Yeah, so thank all of you for your collaboration, uh, Bob and Kathy, and all of your leadership and your faculty have really contributed to not only, um, mitigating this pandemic but really mitigating the impacts of, uh, issues that have affected health equity, not only the school of medicine but in this country and worldwide. So today I wanted to combine, as you heard, some of the learnings that we are starting to just delve into around social determinants of health. What are the stakes? And we will talk a little bit about COVID-19 as an example, but I want to lay the groundwork because we need to understand the definitions. Why are we talking about social determinants, and what can we do about those as academic individuals?
So first of all, if you look at the Healthy People documents that the Surgeon General puts out every 10 years, social determinants of health feature very prominently in the Healthy People 2030 documented. These are aspirational goals that we set for ourselves as a country around public health, and you can see that these are conditions in the environment, um, and as we like to say here at Stanford, you've heard the dean say this in the past, your zip code will predict, uh, your health outcomes better than your genetic code. And this is a really good example of what that means. So you see things like health care access and quality, neighborhood and the built environment, social and community context, economic stability, and education access and quality. These are things that affect your health much more than your health care provider and whether you get the medications that you need. In fact, you could argue that your ability to avoid medications altogether is dependent on all of these factors and more.
Similarly, when you look at this data around a wide frame in terms of societal conditions, we've seen a number of studies, but I just highlight two here, courtesy of the World Health Organization and others, uh, on the left here looking at the United States and on the right the Canadian research looking at, uh, different factors that affect health. And you can see that the impact of social circumstances and environmental exposure and socioeconomic conditions affect about 50 or more of the, uh, medical and health outcomes. So we're not moving, we're moving away from a disease model to a health model, and you can see that genetics, uh, play a very small role. Health care plays an important role, but still not as big as the roles that we see around social determinants. And then similarly, when we look at the Pan-American Health Organization model for social determinants, and there is one for the World Health Organization as well, but I'll explain a little bit later why I think that the Pan-American model really focuses better on what we're dealing with here in the Western Hemisphere, but you can see that these are many areas that we think are going to be important when we as academics and clinicians and community-engaged physicians and health care providers really start to think about how do we improve health, not just how do we prevent disease. We need to take things into account like intersectionality, structural drivers, conditions of daily life, um, take action around governance and human rights, and then finally, these things should all eventually lead to more health equity and a dignified life. And I'll talk again at the very end about these in a little more detail.
And importantly, for those of us here in an academic medical center, uh, it's important to note that the National Institute of Minority Health and Health Disparities does have a very nicely laid out and well-evidenced research framework. You can find it on their website that looks at domains of influence, levels of influence, and health outcomes. And you can see that the levels of influence go from the individual to the interpersonal, the community, and the societal, and then the domains go from biological behavior, the physical and built environment, social, cultural, environmental, and the health care system to impact outcomes at the individual level all the way up to the population health level. So we know that the NIH is committed in dollars and in research, right, priorities to helping us understand all of these different mechanisms, and all of our investigator and large program grants can be addressed, uh, to one or more of these areas of importance around improving wellness rather than just addressing disease.
So how do social determinants of health manifest in the real world? What do we mean by this? Well, first of all, if you look at economic stability as a social determinant of health, you can see very quickly how real median income is dictated by race and ethnicity in this country. If you look back to, um, from 1967 to 2017 from this study, um, that was, uh, written up by one of my colleagues, Fernando Mendoza, in the department of pediatrics, we see that there are very clear racial and ethnic disparities in income, uh, when you look at Black and Latinx populations compared to, um, all races, White, Hispanic, and Asian. There's clearly a stepwise progression where they're all doing better, but there's still disparities among income. Yeah. If you look further here from 1983 when we started to look at Hispanic families in particular and split them out from just non-White, um, uh, uh, and and White, uh, individuals, you can see that the disparities for Black individuals, uh, in 2016 were actually worse, although the numbers were a little better overall in terms of absolute dollars, the difference between White and Black populations was actually worse than it was in 1983, and the Hispanic population as well has seen, um, uh, also a disparity over that period of time.
And then when we look at education access and quality, one marker, for example, is the average National Assessment of Educational Progress mathematics scale, and you can see very clearly that there are very flat patterns here of advancement in, uh, mathematical markers or mathematical achievements in our children based on race and ethnicity, and these really have not changed over a period of, of more than 20 years. And this is an area again that needs that really does reflect on, um, how well people do in the long run in terms of health, and we'll talk about how that happens later. And then if we look at uninsured rates for the non-elderly population by race and ethnicity from 2010 to 2018 from the Kaiser Family Foundation, we can see that overall, fortunately, uninsured rates have dropped over time, particularly in the last five to seven years or so, but there's still very, very clear and discreet discrepancies based on race, ethnicity, and uninsured status. So we can talk about these issues and understand that as a taken, as a whole, they do impact our ability to have access not only to care but to other environmental factors that will keep us healthy, um, and help us, um, uh, help us move forward, not just by race and ethnicity but as a global community.
And we like to talk about this idea based on a paper by Williams and Lawrence Atal, understanding how discrimination can affect health, the house that racism built. So when we talk about institutional racism, we want to not focus on blaming individuals but actually say looking at how well structures have incorporated racism into their institutional process and the fiber of who we are. And in order to, um, de-objectify individuals, we can then approach this in a more, um, more focused way and stay away from feeling guilty, feeling defensive, and saying these are institutional challenges that we need to deconstruct. So if you look at racism as a societal system here on the upper left, you can see all of the factors, including social forces, cultural racism, institutional racism, and individual discrimination that really either that are bi-directionally engaged based on all of the factors we just talked about: income, education, employment, housing, wealth, health, incarceration, stress, resources that are available at the individual and the collective, and that then lead to stereotypes, implicit biases, explicit biases, and stigma. And then these then feed, have a feedback loop on this racism model. So you can see how this is not a simple model; it's very difficult; it's been very hard-wired into who we are as a society, and understanding this, just like anything else, can help us deconstruct it and tease it apart.
Now, what are some specific examples? Well, I won't go into a lot of detail; there are many, many examples of distrust in the medical establishment in particular and how that affects us as health care providers and our patients. So historically rooted distress of the medical establishment, um, I'm just going to give, you know, two very well-known examples. So the story of Henrietta Lacks and the HeLa cells is one very, um, striking, um, example of how people don't trust, have not trusted systems, uh, when which they were not told about cells that, um, their mother, um, and, uh, sister, cousin, um, had cells taken from her. This was, um, something that I think people have pointed to is one area that is a focus of distrust. The U.S. also has a long history of forcibly sterilizing, uh, Black, Brown, and Indigenous populations. Now ongoing institutional oppression, even now, we know that Black and Latinx individuals represent 30 percent of the U.S. population but only six percent of federally funded clinical trials. Um, there are many reasons for that, but those are issues that need to be overcome. And then a very specific example that comes from Dr. Eleni Leos here in the department of dermatology who really, uh, showcased this particular issue very early in the COVID pandemic. She made a point to publish a paper demonstrating that all of the cutaneous manifestations of COVID-19 were really depicted in pictures of people with lighter skin. So just from a clinical standpoint, it was very difficult to identify COVID-19 manifestations. So this is a really subtle example but one that is pervasive in many different areas of medicine.
So what about access to quality healthcare as a social determinant? Well, we want to obviously, uh, support our workforce diversity, and we know that this is important. I think most of us understand that a lack of workforce diversity presents a barrier to access, and, uh, there are many papers now written, some of them here from some of our own colleagues here, Matthias Bruzoni in surgery, who's actually done work around this, showing that underrepresented minority physicians are more likely not only to care for minority and vulnerable patients but actually patient care and satisfaction is better when people can relate to their own physician. Racial concordance may result in longer and more satisfying visits, higher preventive service utilization, and greater access to needed services. Now, we are not advocating to match our patients by demographics at all, but improving the diversity of our workforce can bring that cultural context to all of our providers so that we have a much richer approach to all the patients that we will see, um, and they will then see that as well and sense that.
So how does bias among health care workers impede our access? Now, most of this, of course, is implicit. We are not personally racist individuals; most of us really don't think of ourselves and are really obviously out to do the right thing for our patients, but again, given that a lot of these institutional biases are ingrained, it's very hard for us to get away from those unconscious biases. So there are two general pathways that we think about around provider implicit bias: one is judgments and decisions about patient care, and I'll show you some examples that can lead to disparities in health based on race, ethnicity, or other factors such as the size of the person, the ability of the person, gender, etc.; B is around communication and trust, which we talked about leading to a potentially a reduction in patient engagement and adherence to treatment, which again will result in disparities. So these are things that happen in real time just about every day around the, around this country and the world.
Now, I want to talk a little bit about this Project Implicit. It's a really nice, um, implicit, um, aptitude test that can be taken; it takes about five minutes to do, and it's a really, uh, it measures your underlying unconscious association. So it'll give you words, and you associate the words together, and it will tell you how you unconsciously think about different groups, for example, racial, ethnic minorities, overweight people, people with disabilities, etc., and awards that are favorable or non-favorable, but they are subtle. So you can actually take this and, um, for example, you can say that one has an implicit preference for thin people relative to fat people if they are faster to categorize words when thin people and good share a response key and fat people and bad share a response key. So these are implicit, very rapid thinking kinds of tests, and so if you look at some of the results of these tests, and you can do this online, it's very easy to find this IAT test and take, take it for yourself. In a study of 58 academic pediatric faculty leaders in 2015, and you can see here on the left the graph, a majority had a slight pro-White and anti-Black implicit bias as measured by the IAT provider bias, and there are many other examples, but, um, I, I will leave you to take that test if you want to see and understanding these biases can actually help you deconstruct them in your own mind as you try to understand how can my cortical thinking help to deconstruct these implicit biases that I did not know I had. Racial and ethnic minority children, for example, are less likely, because of provider bias, to be diagnosed with ADHD and less likely to be prescribed medications when...
They are diagnosed; they are less likely to receive analgesics for post-operative pain, to undergo head CT when considered for low or intermediate traumatic brain injury, to undergo advanced imaging for abdominal pain. And actually, a paper just came out this week showing that Black and Hispanic children are less—are have poorer outcomes in cancer treatments. And we know that that’s true as well for adults. And again, if you delve deeper, we have to see why is that? Are they coming to care later? Or are there other biases or other structural issues that prevent them from having those better outcomes? Provider biases regarding minorities’ competence and behaviors contribute to reduced rates of insulin pump use in Black and Hispanic families as well. In a study assessing providers’ implicit bias towards American Indians, for example, 84 percent of providers had an implicit preference for non-Hispanic White adults or children. The American Indian children were seen as increasingly challenging, and um, parents and caregivers as less compliant as the proportion of American Indian children in the ED decreased.
So let’s move on and talk about other factors that affect our health care workers and biases. And again, I’m only focusing on health care workers—this is the Medicine Grand Rounds—but clearly bias affects all of us in every um, in every profession. But stress—uh, when impacted by clinical uncertainty, a high workload, and fatigue—certainly things that we’ve all been facing over the last 19 months—we are more likely to take these mental shortcuts, these implicit shortcuts when making decisions. And in the clinical setting, those that stem from racial biases can have a detrimental impact on the care of patients.
Um, COVID-19—we know all of you know more than anybody that COVID-19 has strained us all in ways that we never thought possible—and certainly bias is one area that has been impacted. The additional strain on provider resources, staff, and supplies created by COVID-19 may exacerbate provider susceptibility to implicit bias and contribute to health disparities. We are at risk for psychological distress, including burnout, sleep deprivation, and anxiety. And this actually can stress us into creating more cognitive shortcuts; that’s that’s actually a defense mechanism. And of course, uh, all of the everyday changing protocols around COVID-19, the uncertainty has certainly exacerbated that stress and anxiety. Clinical guidelines may lead to bias as well. So, in alignment with the UTI testing guidelines released by the American Academy of Pediatrics in 2011, there was a model developed by the University of Pittsburgh for predicting UTIs in children, assigning lower risk to those identified as fully or partially Black. And there’s a long history around why that happened; it had to do with the way the data were collected, and I and um, this actually could affect the ability of Black or African-American children to be diagnosed with UTIs. And I can tell you right now there is a debate at the American Academy about whether or not to really change these guidelines. So um, it’s very clear that people want to do the right thing, and but we need to understand why the evidence may or may not be flawed when you’re using race and ethnicity as a clinical marker.
So let’s talk about COVID briefly. So we talked about social determinants of health and what we know; we talked about them at a high level. What does this mean to our front workers? Well, all of us have cared for COVID-19 patients; we’ve heard their stories; we’ve lived through their family issues. And I know that one thing that has touched my own life is just watching the individual stories of the patients that we took care of during our making our clinical trials and understanding what people were going through on a day-to-day basis. So we know, for example, that people with socioeconomic distress, those who have limited resources, are more likely to be in poverty, to have frontline jobs that put them in contact with people who may be at higher risk for disease. These socio-demographic profiles lead to limited job and economic security and jobs with either lack of adequate PPE or absence of PPE altogether in certain job settings. In on a personal level, crowded living spaces—we know there are data now from a number of papers that show that the density of a household is a major risk factor for transmission and acquisition of COVID-19—and these are areas, of course, where social distancing may be impossible in households where there are few spaces for a few living spaces. Reliance on crowded public transportation or public transportation at all is another marker; many people don’t have cars. I know when we were dealing with the pandemic and even today, how do we transport people with COVID? Many of these people have to take buses. Food deserts or swamps can not only exacerbate existing underlying health conditions, but they can increase the risk. We have talked to pediatricians, for example, in our community where who have seen children, young children who’ve had 20 and 30-pound weight gains over the course of the pandemic because they haven’t had access to outdoor activities; families who may leave them at home because they have two or three jobs and no access to childcare. So we know that there are a lot of social determinants that are impacting directly our health. And then, of course, inadequate insurance coverage leads to the self-rationing of healthcare.
Um, I spoke to a number of people who we knew may have COVID when we were treating patients for antiviral studies and and looking at epidemiologic studies as well, and many people didn’t want to be tested because they didn’t want to know if they were not sick enough; if they were sick and were COVID infected, they didn’t want to have to miss work because they had no choice; they said, “We are the only caregiver; I can’t do this.” We also had a story of a family who both parents came in; they had two children; they came all the way from um, the away in the East Bay, past Livermore and Tracy to Stanford, and they had to decide which parent was sick enough to be hospitalized; they both needed to be hospitalized, but nobody was at home to take care of. So we’re talking about issues that really affect very fundamental uh changes in the way we view health as a result of COVID-19. Now, what else happens with COVID and social determinants of health has to do with what the economic impact of this disease has been in our population. This is something that we really have not measured well with other diseases, and I think it does bear the social inequities in a good way because now we know how disease can impact things other than uh whether you can see it, go to a clinic, or whether you can take your medication. You we’ve seen here that by the survey by the Kaiser Family Foundation identified experience loss of employment, income, difficulty paying usual household expenses, and even worse, food insufficiency in households. And you can see that the numbers are striking; almost half of the population surveyed had these major economic impacts in the family. And unfortunately, the food insufficiency, although fortunately the number is relatively low, it’s still distressing to see this happen, especially when you see children in these households. But you can also see when you break it down by age and race and ethnicity that there is a disproportional impact on our racial and ethnic minorities because of the reasons we talked about before.
So let’s talk about what we can do. How can we address these distressing issues? I think we’ve had to pivot very rapidly in the last 19 months because we are in an academic medical center. I think we have the opportunity to start to think about how to take these issues apart so that we can then in real time make policy and address them. The Social Vulnerability Index—it turns out—is an index that has been put together by the CDC, and it’s been around a long time. I think it was really under the radar because we really weren’t thinking about vulnerability when we had our disease model. But when you think about your health model and your social determinants model, this is one way to identify ways to in to understand and intervene. And I have to say that this is not the only model; the state of California has a model called HPI, and many states have their own models and others as well that can identify social vulnerabilities. It is really a nice model, though, for all of us because it measures social determinants using U.S. Census data. So you actually can track in an open database approach uh Census data for the entire U.S. and all 3,000 six counties in the U.S. Um, and it ranks each county and census tract on 15 social vulnerability factors and groups them into these four related themes around socioeconomic, housing composition, racial and ethnic minorities, and housing and transportation. And here’s an example of how that could work. So this is an older slide from last year, but it does really um demonstrate how you can use the SVI to track disease, and I’m going to go into a little bit of depth here in the next couple slides. So on the left, you see in blue the vulnerability index in quartiles from the highest vulnerability scores to the lowest, and the darker bars are the more more vulnerable counties and census tracts. And on the right, you can track, as of a year ago, COVID-19 cases per 100,000 residents. And you see that these don’t match exactly, but they’re pretty darn close. And how is this important? Well, first of all, it lays bare a problem, but secondly, you can use this to address that problem at a very local level. So if you look at the social vulnerability and risk of a COVID hotspot, you can—we’ll take a look at this study where they took these quartiles—so lowest vulnerability being quartile one and highest being quartile four—and trying to delve deeper into some of those 15 factors. So here you see that in those that map that I showed you, counties with the highest social vulnerability had greater risk of being a COVID hotspot. So we know, for example, that as you could see in the map that those areas that were darker blue also were darker red uh with respect to vulnerability to COVID. Now, when you then broke it down by what type of county, you can see that overall the relative risk of quartile four versus quartile one was uh 2.4. So these quartile four were two and a half times a little more likely to have risk for COVID hotspots. However, if you break it down by region uh type of area around the country, you see that non-metropolitan areas we have 15-fold higher relative risk compared to other areas of the country. And then if you break it down even further to look at its higher percent of racial and ethnic minority residents, that really becomes a an eightfold higher risk in non-metropolitan counties compared to uh urban and suburban type counties. However, if you look at higher percent of housing structures with greater than 10 units, that number really goes up in the metropolitan and um small, medium metropolitan areas compared to rural. And then percent of households with more people than rooms again comes back to the non-metropolitan counties. So if you’re a health count if you’re a county health department or a state health department or an academic researcher searching to understand these factors, you can take these apart, and for each county and census tract, you can understand what the factors are, whether there are unifying factors across counties across states or whether there are specific areas, and then craft interventions to try to address some of these. So if you look here among hotspot counties, again, areas with the highest vulnerabilities had markedly higher COVID incidents than those with less vulnerabilities, and you can see quartile four in particular stands out as having the highest risk by far of COVID hotspots than the other three quartiles combined.
So what does this lead to with COVID and coming back to the stakes for this particular disease? We see racial and ethnic disparities in COVID-19, and when I say talk about this slide sometimes I accidentally say HIV because back in the HIV days this was the same exact thing that we saw; we saw racial and ethnic minorities who had higher risk of cases, hospitalizations, and deaths by by race and ethnicity. We are all familiar with this type of data, and but one one of the things that I remember talking about as a young faculty member and HIV is this is not a biological driver; this is a socioeconomic driver, and we can’t label people as bad or good people because of race, ethnicity; it’s about the conditions in which they live. And so I think we are much more uh in tune to that now; we have data that we can start to track, and this is a really good example of what happened to us even earlier this year. And then similarly, if you look at death tolls among Black and Indigenous Americans over time—so this is from April of 2020 just through August of last year—so again, older data, you’re seeing again those health disparities based on race and ethnicity that are very clearly spelled out here again by my colleague Fernando Mendoza. What happened in California is very similar; we do have a different demographic makeup overall; we tend to have more Latinx and Indigenous populations here, but it has we have seen, as all of you know who have taken care of patients, a disproportionate impact on cases and deaths among the Latinx community relative to their proportion in the uh and the California population and also among other Indigenous populations as well.
Now, if we look at this from a global scale, I want to talk a little bit about the global population and global equity. Remember, we also have to think about this disease and others as really uh reflecting um our own ability to control disease in this country because we want we if if we want to control disease in this country, we need to think about what’s going on elsewhere, but also because we are a global community and we need to think about global equity. And so if you look here on the left, the percentage of global population 18 years and older in high-income versus low-income countries, you can see that we in the high-income area of the world represent about one-fifth of all individuals over 18, and yet we are getting over half of all the vaccine doses in this country. This was something that we predicted last year based on contracts that were put out, and it has it has continued to occur. Now we are seeing some progress in this area, but clearly it’s not just about COVID vaccine; it’s about all of the equity, equitable access to healthcare around the world. And so this is just a stark example of how that plays out.
So how do we address social determinants? Again, this is a very high-level discussion; again, coming back to the PAHO Commission because I thought they did such a great job of talking about the interactions of all of these. There are structural drivers; inequities in power, money, and resources to uh these impact achieving equity and political, social, cultural, and economic structures. One of the things I like about um or two of the things I like about the PAJO model more than the WHO model is they talk about the natural environment, mitigating climate change, and respecting relationships to land, given that we still have a vast majority of the Western Hemisphere in which Indigenous people are being deprived or being pushed off of their own land, and the impact not only on them directly but on on all of us because of climate change; reversing the health equity impacts of ongoing colonialism and structural racism. So these are areas that many of us feel like, “What can we do about this?” But if we can start to address these at an academic level, understanding these issues, then policy can follow. Conditions of daily life are important; equity from the start. As a pediatrician, I obviously believe in this life course approach, and I think we’re all starting to move in that direction: decent work, dignified life at older ages, income, reducing violence for health equity, improving the environment, and equitable health systems. And then finally, this is the big picture here: how do you govern for health equity? Clearly, we have not gotten there in the Western Hemisphere or the world at large, but government arrangements for health equity and fully and fully fulfilling and protecting human rights are going to be one way where we can achieve health equity overall.
So how do we reach our marginalized population? This is another area; we need to have them at us, give them a seat at our table, especially when we’re doing community-engaged research. And I know that here at Stanford we have really launched some major efforts in community-engaged research through the Office of Community Engagement and through a lot of the work that’s being done here in the Department of Medicine as well. And I’ll talk a little bit about that; talking to our local leaders, community and faith-based organizations are community groups and health centers; working with and not for communities is critical. And then the last couple slides I just want to showcase what it is that all of you are doing and my gratitude for the work that people have done, given the many stresses and strains that we have seen; people have really stood up a number of different opportunities and really pivoted. And here are some leaders that we see some of from our your own department here of Medicine; our Health Equity Action Leadership Network. This is something that we launched earlier this year through the Office of Faculty Development, Diversity to develop scholarship, disseminate resources and funding opportunities, and foster collaborations around research. And these are some of the pilot grants that we did give out earlier this year around COVID-19 and health disparities issues that are important to families around prematurity, demographic biases and COVID-19 in the Medicaid population, food insecurity in the Latinx population uh during COVID-19, improving telehealth access was a really big one as well. So these are all projects, and if you get a chance to go to our website and look at these, the results are really interesting even in the last few months since these grants have been given out; a lot of work has been done, and actually several papers have already been published by these um by these uh authors and these uh fabulous faculty members.
So in summary, factors such as economic stability, access to quality education, and experiences of racism have downstream impacts on access to quality healthcare and health overall. Bias among health care workers negatively affects the quality of care. COVID-19 underlines these disparities; it did not start with COVID-19, but this is an opportunity that we have to address it now with interventions that aim to improve the conditions of daily life. So I’d like to stop there and thank you for your attention. [Applause]
Well, no, thank you for that, a wonderful presentation. My main question is just how do you find the time to do all the things that you do for all of us? It’s amazing, uh, but thank you so much for being such a leader and model in so many ways. I want to stop and I mentioned in Chad, um, for those of you uh on Zoom, please know you can still ask questions just like we are and Zoom. I know it’s a little different today since we’re in Berg, but if you do have questions, please send them in. I do have a question for Dr. Wynn; I’m going to send the mic over to her right now. Thank you; that was an amazing talk, and thank you for being having us back in person. Um, you know, I was struck by the lack of change in the data from the HIV to to the COVID pandemic, and we know there will be another pandemic. What are some in terms of thinking about a roadmap for the next pandemic, what are some of the one percent changes that we can make to achieve that rather than thinking of from zero to a hundred? You know, that’s a great question. I think recognizing this is an issue; I think I don’t think we’ve ever seen it in in the history of um of our medical care systems uh such a spotlight on social determinants of health. This is a real opportunity; we talked about it many years ago, but I think COVID has again, as we talked about, really highlighted a lot of things that were not working well with our healthcare systems, with our public health structures. And I’m hoping that as researchers, first of all, as researchers, we can start to delve more deeply and understand what are the triggers that affect health so that our policymakers—and we know we have a new Department of Health Policy; Doug Owens and his group are going to have a lot of work ahead of them to help us put some of this into policy—and then finally our clinicians can really recognize not only their own wellness and self-care that lead to some of their implicit biases, making sure that we understand the cultural context of our patients. And I think most of us do that now, but I think we could be more aware of that. So it is going to take it’s a step-by-step approach, but we certainly at least are acknowledging better than we did back in the 80s and 90s with HIV. Dr. Harrington, so Bonnie again, thank you.
Thank you for everything you've done. And I, I had the same question Errol had, which is, wow, how does she get all of this stuff done? It's really, it's, it's impressive.
Um, as you know, I'm a cardiologist, and I'm very interested in what we can learn from the pandemic in terms of how we think about a public health construct for chronic diseases, including cardiovascular disease. As a public health expert, infectious disease expert, any comments on that and how we relate the pandemic to the global epidemic of cardiovascular disease?
You have some fabulous researchers in your own department who are trying to address those issues now, and I don't want to, you know, uh, steal your thunder here, but you can talk about some of those people who are doing the work now. And that is understanding how we measure disease, acute or chronic, um, really isn't just about the disease itself, but how we measure people's overall, um, uh, living condition. So, for example, Fatima Rodriguez, as you know, is looking at risk factors for cardiovascular disease. If you don't ask the right question, you're going to miss the answer; and so, or if you don't even address the population, you're going to miss the answer. So she's very clearly shown in our recent fireside chat that we had that when you look at your cardiovascular risk, you know, it's either white, black, or other. And so if you're not measuring certain populations, you're going to miss that risk, and I think that's a really good place to start is to be a little more multi-dimensional, or as we like to say, intersectional about how we understand this. But I think that's one of the first steps. And chronic disease clearly is doesn't just appear out of nowhere. So understanding those steps does take a big investment, and that's where I think NIH needs to really step up and continue to fund. NIMHD has a great model, but frankly, they're one of the poorest funded institutes at the NIH. So you know, I, I think they need to, we need to get a better sense of what are the roots and how do we get from those roots to the full-grown uh, chronic illness.
So absolutely, uh, chronic diseases are just as important, if not more important. Dr. Maldonado, we're just hitting nine o'clock now. I wanna again thank you so much for everything you've done for us on multiple facets. Thank you for being our honor honoree of our first in-person grand rounds. I'm looking forward to more, and thanks again. So thanks everybody for joining, and those of you who are still online with us as well, we'll close it up. Thanks so much.