Hawa Tunkara, MD (’23)
Health equity has become a popular phrase used in public health and in medicine—often mentioned in organization’s missions, priorities and aims. In medicine, naturally health equity feels inherent in our work as we work towards good health for our patients. To me our job as physicians directly equals achieving health equity.
Health Equity carries many definitions, but a central theme is: having equal opportunity to live a healthy life 12345. Physicians often find themselves taking care of a patient whose health is a product of factors they cannot not exactly control. We can all likely think of a patient whose social circumstance created barriers in their treatment plan. We are trained to take care of the patient in front of us. However, if healthy equity aligns with our work where is our place to tackle the structures that make our patient’s sick?
In the U.S, one can look in any state or city and see alarming data that show that certain groups of people (people of color, immigrants and low-income) consistently have the worst health outcomes. And when juxtaposed with the country’s most privileged groups, the differences in life expectancy and disease burden is stark. These differences in health outcomes lead us to other popular public health terms such as health disparities and health inequity. However, to be clear health inequity, the opposite of health equity, are not just differences, they are differences that are unjust and unfair.
Let’s take a look at Rhode Island. Using 2022 RI Kids Count data, we can see differences in health outcomes along the lines of race/ethnicity and location. In fact, it is no coincidence that the core cities, defined by RI Kids Count as Rhode Island communities with the highest percentages of children living below the poverty threshold, have the highest rates of lead poisoning and emergency room visits for asthma7 (Table 1). Along the lines of race/ethnicity, the highest rates for infant mortality, low birth weight, obesity and ED visits for asthma are in individuals who identify as Black or Hispanic (Figure 1-4)678.
The COVID-19 pandemic also demonstrated these health inequities, with total cumulative data from U.S states showing that minority groups: Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander, have experienced higher rates of COVID-19 cases and deaths compared to White people9.
Table 1: Lead Levels and Rates of Emergency Room Visits in Core Cities v. Remainder of RI
| City/Town | % of lead level > 5 u | Rate of Emergency Room visits for Asthma per 1,000 children (< 18 yo) |
| Central Falls | 8.0% | 9.8 |
| Providence | 6.6% | 10.4 |
| Woonsocket | 4.5% | 8.9 |
| Pawtucket | 4.4% | 7.4 |
| Rest of RI | 1.9% | 3.2 |
| Source: Rhode Island Department of Health, Emergency Department Visits and Hospital Discharge Data, 2016-2020. | ||
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In medicine we do a decent job taking care of the down-stream effects of health inequity (e.g. taking care of the patient with a severe asthma exacerbation in the emergency room); however, we can maximize patients’ health by addressing more upstream/root causes of health inequity. Places that are already doing this are health departments, including the Rhode Island Department of Health (RIDOH). Broadly, local and state health departments serve as an entity that promotes public health within their jurisdiction. RIDOH which serves as the state and local health department for all of Rhode Island actually includes health equity in their aims. And in line with this, there is designated section in the health department called the Division of Community Health and Equity (CHE) which works towards this. This division is divided into the: Center for Chronic Care and Disease Management, Center for Health Promotion, Office of Maternal and Child Health, Center for Perinatal and Early Childhood Health, Center for Preventative Services, and Office of Special Needs. Each division has its focused programs and program managers who work towards RIDOH’s aim to promote health equity. See below to learn about high yield RIDOH resources that may apply to our pediatric patient population.
Since we interface often with groups who are on the receiving end of health inequities, it is important for us to be aware of or have avenues for eligible patients to access programs that can bridge the gap. As physicians, our road towards achieving health equity cannot just focus downstream; we have much to learn from leaders in public health.
High Yield Rhode Island Department of Health Resources:
(List is limited to individuals I was able to meet and data available)
Health Equity Zones (HEZ) are community-led collaboratives in a geographic area (e.g. Central Providence) that tackle root causes of health inequity. It is a model where the community identifies their priorities to the Health Department. The community assesses their own health needs and creates assessments and an action plan. Then the health department helps with writing grants and funding.
Asthma Programs
- Draw A Breath Program: Community Asthma Program that offers classes at Hasbro, schools, community sites and offers a camp.
- Home Asthma Response Program (HARP): Free home visiting program which offers comprehensive home evaluation, teaching, and free supplies.
- Eligibility: Age 2 -17 with severe asthma and has a ED visit > 2 in the past year or admitted for asthma in the past year.
- To refer, call: 401- 444- 8340
- Breathe Easy at Home: A program that helps families improve living conditions in their home. Helps facilitate home inspections, identify violations and includes follow up.
- Cool it off: A program that helps families who live in Providence Housing Authority who have a child with Asthma get a free air conditioner, $25/month to help pay electricity bills (July – Sept).
- For more information, call: 401- 222- 6272
Substance Exposed Newborn Program
- Substance exposed newborns is defined as an infant exposed to any substance that can have short-term and long-term harmful effects (e.g. opioids)
- All substance exposed babies get an automatic referral for home-based services
- All substance exposed babies get discharged with a plan of safe care, which in brief outlines the health needs of the newborn, and substance use disorder treatment needs of the parent and/or caregiver
- There is a task force to help develop recommendations for screening and DCYF involvement
Safe Sleep Program
- All families are provided with a Safe Sleep book (available in Spanish & English) at the time of discharge from birth hospital
- The program gives provider trainings for EI, Home Visiting Programs, WIC with hopes that they will screen for safe sleep
- Home visiting programs perform a safe sleep assessment
- Provide free pack and plays, and sleep sacs through First Connections
Youth Suicide Prevention Program
- In January 2021, Suicide Prevention–The Nathan Bruno And Jason Flatt Act was passed. It mandates that there is annual suicide awareness and prevention education in middle and high schools and that all school staff (including ancillary staff) are also trained in suicide screening
- Pedi PRN/Bradley Access Center
- Community Programs at schools, including lay-person training
References:
1. Rhode Island Department of Health. Rhode Island Health Equity Measures: Department of Health. Rhode Island Department of Health. https://health.ri.gov/data/healthequity/
2. Centers for Disease Control and Prevention. Health Equity. Centers for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/healthequity/index.htm
3. Bravemen P, Arkin E, Orleans T, Proctor D, Plough A. What is Health Equity? Robert Wood Johnson Foundation. Published 2017. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html
4. Centers for Medicare & Medicaid Services. Health equity. Centers for Medicare & Medicaid Service.s https://www.cms.gov/pillar/health-equity
5. U.S Department of Health and Human Services. Health Equity in Healthy People 2030. U.S Department of Health and Human Services: Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030
6. 2022 Rhode Island KIDS COUNT Factbook. Rhode Island KIDS COUNT; 70 -73
7.2022 Rhode Island KIDS COUNT Factbook. Rhode Island KIDS COUNT; 76 -79
8. 2022 Rhode Island KIDS COUNT Factbook. Rhode Island KIDS COUNT;82 -83
9. Hill L, Artiga S. COVID-19 Cases and Deaths by Race/Ethnicity: Current Data and Changes Over Time. Kaiser Family Foundation. Published February 22, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-cases-and-deaths-by-race-ethnicity-current-data-and-changes-over-time/