Talking about racial health inequality in Boston
What does it take to tackle a multifaceted problem?
- An estimated 80,000 people of color die because of racial health inequality every year.
- There are a variety of interventions that can be made.
- In Boston, it's worth thinking about the access to public transportation people have in Jamaica Plain and Roxbury.
It is crisp in Boston. Scarfs are out. Just around the corner from a cavernous atrium-styled hall at Harvard Medical School, questions were collected from the gathered audience in a lecture hall in advance of Dayna Bowen Matthew showing up to talk about racial inequalities in health care outcomes based on a book she wrote in 2015 called Just Medicine. One person spoke about a hospital putting a protocol in place to ensure that — when someone was transitioning — they would personally feel welcome at every stage of their transition. Another spoke about students volunteering to provide medical care on the streets of the city and how transformative even a month of that was in terms of fueling empathy, humility, and more. A third person almost came close to holding a personal psychotherapy session in public about their time spent as a mother in Princeton, New Jersey.
But all that served as a prologue and none of it spoke to the idea of pursuing immediate solutions to address racially unequal outcomes in health care.
That's where Matthew steps in. In Chapter 8 of Just Medicine, Matthew outlines what she calls "a structural solution" based on Dr. Thomas Frieden's work, which argues that "the effectiveness of public health interventions decreases at the higher levels of the pyramid" — which you can see above — "while interventions aimed at the broad, lower levels of the pyramid have the greatest potential to improve population health outcomes."
But that's a way of organizing existing modes of trying to deal with implicit biases, not a reveal of a specific program to tackle biases in and of itself. CLAS standards (culturally and linguistically appropriate services) are insufficient, in the book's recounting. Languages access services aren't provided in a timely fashion. A variety of qualities regarding interpreters falls short. What's more, "organizational pressures, multiple competing demands and resource constraints inhibit preparedness." (This being a sentiment that shares a potential overlap with some of the structural factors causing burnout and depression with Doctors.)
"Disparate health care quality measures have improved in absolute terms between 2002 and 2010," Matthew wrote in the book, but "the gap between quality improvements for whites and people of color has been relatively constant." She continued —
"Some examples of widening gaps between whites and minority patient quality outcomes include the number of maternal deaths in childbirth, the number of infants who receive vaccines, the number of diabetic adults who get their glucose levels tested annually, the incidence of breast cancer diagnosed at advanced versus early stages, the number of adults over age fifty who receive preventative care in the form of colonoscopy or other diagnostic procedures, and the number of children for whom a health provider gave advice about using car safety seats."
Matthew ultimately advocates for a law banning implicit and unconscious bias, likening it to a ban against smoking, but if education regarding the daily practice of civil rights fell enough by the wayside in the aftermath of passing the Civil Rights Act for enough people that it reached the point where Chief Justice John Roberts could argue that there was no longer a need for the Voting Rights Act, then the amount of work it would take to educate everyone on what constitutes an unconscious bias — something someone might not even be aware of — could very well be a lot, even if implicit biases have been shown to be malleable.
But that doesn't mean that Matthew isn't wrong to point out how intricate the problem can be: as she notes around page 204, a health care "providers' negative perceptions of minority patients as noncompliant, uneducated, and uncooperative lead to inferior communication, minority patient dissatisfaction, statistical discrimination, and ultimately inequitable treatment decisions."
And that doesn't mean that there aren't interesting interventions taking place across the country either: in Pittsburgh, Pennsylvania and Greensboro, North Carolina, a group found that — at two cancer centers in each of the cities — "black men and women with early-stage breast or lung cancer were less likely to complete treatment than white patients (81% of black patients completed treatment, compared with 87% of white patients), even after taking into account patients' age, comorbid illnesses, health insurance, income, and marital status." The group addressed the issue by partnering with the Racial Equity Institute to train individuals and made a point of not letting individuals fall behind because of medical illiteracy.The report — put together by The Commonwealth Fund — found numerous other examples as well, including the fact that —
… Focus group research uncovered concerns among many minority patients about the invasiveness and inconvenience of the traditional colonoscopy. Over the years, HealthPartners has leveraged several different tools to try to decrease the gap, including adding decision support and proactively reaching out to patients. In August 2017, the health system sent a home colon cancer screen, known as FIT (fecal immunochemical test), to more than 3,000 patients of color. They also encouraged physicians to avoid describing the traditional colonoscopy as the "gold standard" of screening because it implied FIT was inferior when the U.S. Preventive Services Task Force made no distinction. By the end of 2017, three months after this intervention began, an additional 757 more patients of color had been screened.
All this made one think about where the conversation in lieu of this book talk was taking place and — in particular — the contents of The Boston Health Report, which examined the health of the city for 2016-2017 and notes that "Black and Latino residents continue to experience higher rates of preterm birth, asthma, hypertension, obesity, and a host of other conditions compared with their White counterparts. Asian residents had higher rates of low birthweight births and tuberculosis than White residents."
There were some positive-leaning items in the report — a decrease in rates of asthma hospitalizations, heart disease hospitalizations, cancer mortality, hep C, and homicides — but equity remains a concern, and there are numerous details across the 671 page report that speak to different aspects of that. For instance — as noted on page 17 —
After adjusting for differences in age, race/ ethnicity, and sex, a higher percentage of Boston Housing Authority residents and renters receiving rental assistance had asthma, diabetes, hypertension, obesity, persistent anxiety, and persistent sadness compared with homeowners. Renters who did not receive assistance were more likely to have persistent anxiety and persistent sadness compared with homeowners.
And it makes you wonder how the health of these individuals could be improved if these individuals didn't have to worry about rent. How would the numbers change if there was reliable enough and cheap enough public transportation that individuals could make their appointments on time?
The problem is multi-faceted. There are multiple ways to address the problem. This was reflected by the fact that the audience in the lecture hall continued to collect questions for when the speaker showed up.
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Northwell Health CEO Michael Dowling has an important favor to ask of the American people.
- Michael Dowling is president and CEO of Northwell Health, the largest health care system in New York state. In this PSA, speaking as someone whose company has seen more COVID-19 patients than any other in the country, Dowling implores Americans to wear masks—not only for their own health, but for the health of those around them.
- The CDC reports that there have been close to 7.9 million cases of coronavirus reported in the United States since January. Around 216,000 people have died from the virus so far with hundreds more added to the tally every day. Several labs around the world are working on solutions, but there is currently no vaccine for COVID-19.
- The most basic thing that everyone can do to help slow the spread is to practice social distancing, wash your hands, and to wear a mask. The CDC recommends that everyone ages two and up wear a mask that is two or more layers of material and that covers the nose, mouth, and chin. Gaiters and face shields have been shown to be less effective at blocking droplets. Homemade face coverings are acceptable, but wearers should make sure they are constructed out of the proper materials and that they are washed between uses. Wearing a mask is the most important thing you can do to save lives in your community.
Two massive clouds of dust in orbit around the Earth have been discussed for years and finally proven to exist.
- Hungarian astronomers have proven the existence of two "pseudo-satellites" in orbit around the earth.
- These dust clouds were first discovered in the sixties, but are so difficult to spot that scientists have debated their existence since then.
- The findings may be used to decide where to put satellites in the future and will have to be considered when interplanetary space missions are undertaken.
What are they?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xODgyMDA0NC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNTM1ODc0Mn0.NH33LuauIo__sUBi4tvhwxDcsvhflDFD-Nhx9FjlSNk/img.jpg?width=1245&coordinates=148%2C0%2C149%2C0&height=700" id="cec96" class="rm-shortcode" data-rm-shortcode-id="acb78abe2ab46a17e419ad30906751d6" data-rm-shortcode-name="rebelmouse-image" />
Artist's impression of the Kordylewski cloud in the night sky (with its brightness greatly enhanced) at the time of the observations.
G. Horváth<p>The<a href="https://en.wikipedia.org/wiki/Kordylewski_cloud" target="_blank"> Kordylewski clouds</a> are two dust clouds first observed by Polish astronomer Kazimierz Kordylewski in 1961. They are situated at two of the <a href="https://www.space.com/30302-lagrange-points.html" target="_blank">Lagrange points</a> in Earth's orbit. These points are locations where the gravity of two objects, such as the Earth and the Moon or a planet and the Sun, equals the centripetal required to orbit the objects while staying in the same relative position. There are five of these spots between the Earth and Moon. The clouds rest at what are called points four and five, forming a triangle with the clouds and the Earth at the three corners.</p><p>The clouds are enormous, taking up the same space in the night sky as twenty lunar discs; covering an area of 45,000 miles. They are roughly 250,000 miles away, about the same distance from us as the Moon. They are entirely comprised of specks of dust which reflect the light of the sun so faintly most astronomers that looked for them were unable to see them at all. </p><p>The clouds themselves are probably ancient, but the model that the scientists created to learn about them suggests that the individual dust particles that comprise them can be blown away by solar wind and replaced by the dust from other cosmic sources like comet tails. This means that the clouds hardly move but are <a href="https://www.nationalgeographic.com/science/2018/11/news-earth-moon-dust-clouds-satellites-planets-space/" target="_blank">eternally changing</a>. </p>
How did they discover this?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xODgyMDAzNi9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1Nzc4MjQ4MX0.7uU9OqmQcWw5Ll1UXAav0PCu4nTg-GdJdAWADHanC7c/img.jpg?width=1245&coordinates=0%2C180%2C0%2C181&height=700" id="952fb" class="rm-shortcode" data-rm-shortcode-id="a778280a20f1c54cd2c14c8313224be2" data-rm-shortcode-name="rebelmouse-image" />
"In this picture the central region of the Kordylewski dust cloud is visible (bright red pixels). The straight tilted lines are traces of satellites."
J. Slíz-Balogh<p>In their study published in the <a href="https://academic.oup.com/mnras" target="_blank">Monthly Notices of the Royal Astronomical Society</a>, Hungarian astronomers Judit Slíz-Balogh, András Barta, and Gábor Horváth described how they were able to find the dust clouds using polarized lenses.</p><p>Since the clouds were expected to polarize the light that bounces off of them, by configuring the telescopes to look for this kind of light the clouds were much easier to spot. What the scientists observed, polarized light in patterns that extended outside the view of the telescope lens, was in line with the predictions of their mathematical model and ruled out other possible sources. </p>
Why are we just learning this now?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xODgyMDAzOS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY2MjUyNDMyMH0.Zl8GmQ_rJHiL4b7hN0r_YBmgb6_ZqIRvqOVuko2ubpw/img.jpg?width=1245&coordinates=0%2C141%2C0%2C185&height=700" id="87afe" class="rm-shortcode" data-rm-shortcode-id="dd4c0b5088e601d7279cc5eb226f8b7b" data-rm-shortcode-name="rebelmouse-image" />
"Mosaic pattern of the angle of polarization around the L5 point (white dot) of the Earth-Moon system. The five rectangular windows correspond to the imaging telescope with which the patterns of the Kordylewski cloud were measured."
J. Slíz-Balogh<p>The objects, being dust clouds, are very faint and hard to see. While Kordylewski observed them in 1961, other astronomers have looked there and given mixed reports over the following decades. This discouraged many astronomers from joining the search, as study co-author Judit Slíz-Balogh <a href="https://ras.ac.uk/news-and-press/research-highlights/earths-dust-cloud-satellites-confirmed" target="_blank">explained</a>, <em>"The Kordylewski clouds are two of the toughest objects to find, and though they are as close to Earth as the Moon are largely overlooked by researchers in astronomy. It is intriguing to confirm that our planet has dusty pseudo-satellites in orbit alongside our lunar neighbor."</em></p>
Will this have any impact on space travel?<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="c3d797fff5430c64afcb5a49bddc3616"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/Ou8N3v9SFPE?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>Lagrange points have been put forward as excellent locations for a space station or satellites like the <a href="https://jwst.nasa.gov/about.html" target="_blank">James Webb Telescope</a> to be put into orbit, as they would require little fuel to stay in place. Knowing about a massive dust cloud that could damage sensitive equipment already being there could save money and lives in the future. While we only know about the clouds at Lagrange points four and five right now, the study's authors suggest there could be more at the other points.</p><p>While the discovery of a couple of dust clouds might not seem all that impressive, it is the result of a half-century of astronomical and mathematical work and reminds us that wonders are still hidden in our cosmic backyard. While you might never need to worry about these clouds again, there is nothing wrong with looking at the sky with wonder at the strange and fantastic things we can discover. </p>
New cancer-scanning technology reveals a previously unknown detail of human anatomy.
- Scientists using new scanning technology and hunting for prostate tumors get a surprise.
- Behind the nasopharynx is a set of salivary glands that no one knew about.
- Finding the glands may allow for more complication-free radiation therapies.
PSMA PET/CT technology<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="676e611b970c9b516cace0870447b325"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/RHAyoQF09X4?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>PSMA PET/CT is a new combination of <a href="https://www.mayoclinic.org/tests-procedures/pet-scan/about/pac-20385078" target="_blank">PET scans</a> and <a href="https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac-20393675" target="_blank">CT scans</a> that is believed to offer a more reliable means of locating prostate cancer metastasis. A <a href="https://www.cancer.gov/news-events/cancer-currents-blog/2020/prostate-cancer-psma-pet-ct-metastasis" target="_blank" rel="noopener noreferrer">study</a> published last spring suggests it may be the most accurate way to diagnose prostate cancer metastasis than any method previously available.</p><p>Prior to PSMA PET/CT, the primary way to look for metastatic prostate cancer was to image the body using x-ray-based CT scans and to perform bone scans, since bone is where prostate cancer often spreads. CT scans, however, often miss small tumors, and bone scans can generate false positives as a result of other damage or abnormalities that have nothing to do with prostate cancer.</p><p>PSMA PET/CT scans track the travels of an intravenously administered radioactive glucose tracer throughout the body. For hunting down prostate cancer, this tracer contains a molecule that binds to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472940/" target="_blank">PSMA</a> protein that's present in large amounts in prostate tumors. The molecule is linked to a radioisotope, <a href="https://netrf.org/2018/11/13/gallium-68-scan-for-neuroendocrine-tumors/" target="_blank" rel="noopener noreferrer">gallium-68</a> (Ga-68).</p><p>In last spring's research, PSAM PET/CT was shown to be 27 percent more accurate than previous methods at finding metastases (92 percent accuracy as opposed to 65 percent). In addition, it was found to be much less likely to produce false positives, and it was particularly good at detecting tumors far removed from the prostate.</p>
A good kind of avoidance behavior<p>"Radiation therapy can damage the salivary glands," says Vogel, "which may lead to complications. Patients may have trouble eating, swallowing, or speaking, which can be a real burden."</p><p>The researchers looked back through the cases of 723 patients who had undergone radiation treatment, interested in seeing if inadvertent radiation of the tubarial glands was associated with the complications experienced by the patients. It turned out that this <em>was</em> the case: In cases where more radiation had been delivered to this area, patients did indeed report more in the way of complications of the type one would expect when salivary glands are radiated.</p><p>Now that we know the tubarial salivary glands exist, therapists can stay out of their way. Vogel says, "For most patients, it should technically be possible to avoid delivering radiation to this newly discovered location of the salivary gland system in the same way we try to spare known glands."</p><p>He's hopeful that that things may be about to get at least a bit better for cancer patients: "Our next step is to find out how we can best spare these new glands and in which patients. If we can do this, patients may experience less side effects which will benefit their overall quality of life after treatment."</p>
A new survey found that 27 percent of millennials are saving more money due to the pandemic, but most can't stay within their budgets.