Health Disparities Origins and Opportunities Barry Zuckerman MD

Health Disparities: Origins and Opportunities Barry Zuckerman, MD The Joel and Barbara Alpert Professor and Chairman of Pediatrics Boston Medical Center/ Boston University School of Medicine Chicago, 11/3/10

Race and Health ↓ Poverty Stress/violence Poor diet Poor learning environment Educational opportunity Employment opportunity Medication/other health expenditures Cigarettes and alcohol Poor Adult Health Racism ↓ Unequal Medical Care ↑ Stress

FIGURE 1 -- Probability of having an allostatic load of 4 or higher, as predicted by race (a) and race and gender (b) Geronimus, A. T. et al. Am J Public Health 2006; 96: 826 -833 Copyright © 2006 American Public Health Association

Sickle Cell Anemia: A Special Case Study of Race and Health

NIH Research Funding and Private, Nonprofit Association Support of SCD and Cystic Fibrosis Variable US prevalence SCD Cystic Fibrosis 80, 000 30, 000 90 128 1125 4267 Federal support NIH fiscal-year 2004 funding, in millions of dollars NIH funding person with disease, $ Private philanthropic support, $ Cystic Fibrosis Foundation 2003 annual review Sickle Cell Disease Association of America 2003 annual revenue Revenue person affected with the disease 152, 213, 000 498, 577 5074 6 Total NIH and private support, in millions, $ 90. 4 280. 2 Total support person affected with disease, $ 1130 9340

Number of Federal Government Requests for Applications Funded for Sickle Cell Disease and Cystic Fibrosis: 1975 -2004

Race and Health ↓ Income Poor Health Racism ↓ Access ↑ Stress

Adult Health Disparity by Income

Adult Health Disparities: Life Course Trajectory

Adult Health Disparities:

How Early Experiences Get Embedded in Biology and Influence Health Environment n n n → Social Physical Nutrition productivity → Brain → School failure → Organs Gene. Environment Interaction → Neurochemical Adaptations & Disruptions Poor education & economic ↕ Poor health behavior ↕ Poor physical & mental health

Early experiences are biologically embedded in development of brain and other organs Early Experiences Positive n Nurturing and stimulation Adverse n Stress/harmful interactions n Neurotoxic exposure n Inadequate nutrition Child and Adult Health

Brain Development

Parental Language Addressed to Child by SES Hart & Risley, (1995)

Early experiences are biologically embedded in development of brain and other organs Early Experiences Positive n Nurturing and stimulation Adverse n Stress/harmful interactions n Neurotoxic exposure n Inadequate nutrition Child and Adult Health

Positive and Tolerable Stress

Toxic Stress

Direct Effects of Stress Gianaros, P. J. , et al. Neuroimage, 2007.

Effect Size Between Low and Middle Income Children on Neurocognitive Functioning (N=60) Farah, M. J. , et al. Brain Res, 2006

Odds Ratio Stress: Adverse Childhood Events and Adult CV Disease ACEs Dong et al, 2004

Odds Ratio Adverse Childhood Events and Adult Depression ACEs Chapman et al, 2004

Stress and Genetic Vulnerability for Depression Caspi, A. , et al. Science. 301: 386 -389 2003

Stress and Genetic Vulnerability for Antisocial Behavior Caspi, A. , et al. Science. 297: 851 -854 2002

What to do: Examples 1. 2. Society: comprehensive Health care n Race n n n Regulations tied to new construction Target quality improvement of select hospitals Cultural competency Increase racial diversity among physicians, nurses, etc. Interpreters (technology) Use of non-health care settings n n n Barbers Churches salons

Use Health Care to Disrupt Link Between Poverty and Poor Health Reach Out and Read n Medical-Legal Partnership n Project HEALTH n

Reach Out and Read Advice and books given at pediatric well child visits until age 5

Frequency of Reading Aloud (High et. al. , 2000)

Children’s Expressive and Receptive Language Competencies Mendolsohn, et al. , 1995

Reach Out and Read Statistics ● Founded in 1989 at Boston City Hospital ● Over 4, 500 sites ● Over 3. 5 million children from low-income families reached last year ● Over 5 million books distributed last year

Social Determinants of Healthy Development: Mechanisms 1. Direct: n Deprivation n n Exposures n n n 2. Food Money Health medications caloric food Lead Asthma triggers Indirect: Stress

Specialist saves the day n A 11 yr old boy arrives for an urgent care visit. In the past 2 months, he has needed several courses of oral steroids despite an appropriate medication regimen and an asthma action plan which his mother follows. However, the landlord has refused to do the needed pest control measures you suggested. n The patient has missed school repeatedly and is at risk of failing. n A new specialist was consulted and within 6 weeks, the teen was weaned off steroids and was back in school.

NICU Babies Have Legal Needs Baby Isabel, born 28 wks. Parents are legal immigrants from the Dominican Republic. As a NICU patient, Isabel is eligible for many benefits and services that will protect her health and prevent re-hospitalization: SSI, early intervention, etc.

Parents don’t understand if and how Isabel’s access to benefits impact their immigration status. Frontline and hospital staff – nurses, case managers, pediatricians – don’t know how to advise them. Parents decide not to pursue benefits. Isabel is seen in the ED 3 months later with fever, secondary infection of diaper rash due to diarrhea and FTT.

Medical-Legal Partnership for Disparity Reduction Biological Doctors Childhood Illness Social Lawyers

The MLP Network – March 2009 81 partnerships in over 180 hospital and health centers

Perry Preschool Project: