Impact of Discrimination on Health, Importance of Social Support and Community, Focus of Conference
Speakers share a broad range of research and action taking place across the Medical Center and in NYC
Discrimination based on race, ethnicity and sexual orientation and gender identity has a direct impact on the health of populations, said speakers at the Health Disparities Symposium at NYU School of Medicine on October 18. Sponsored by the Department of Population Health, the Office of Diversity Affairs, and the NYU-Health + Hospitals Clinical and Translational Science Institute, the event drew close to 200 attendees. The event spotlighted the broad range of health disparities research and action taking place across the School of Medicine, NYC Health + Hospitals, and New York City. Speakers focused in particular on how historical discrimination and common stereotypes are related to chronic disease or mental health issues and how this impact is being addressed in New York City, in clinical care, data collection, healthcare systems, and city government.
Aletha Maybank, MD, MPH, deputy commissioner at the New York City Department of Health & Mental Hygiene and director of its Center for Health Equity, gave a keynote that focused on how data mapping and surveillance led to awareness about the causes of high burdens of disease for African-Americans. At the turn of the twentieth century, “the popular theory was that blacks were responsible for making the city unhealthy and dangerous,” Dr. Maybank said. The first chipping away at this notion came with the 1899 publication of a report by then-Harvard graduate student W.E.B. Du Bois about the health of African Americans in Philadelphia. Through collecting and mapping data on the mortality rate for whites compared to blacks—many of them former slaves—Du Bois pointed to the link between race and place for health. Blacks’ health problems were linked to “dwell[ing] in the most unhealthful parts of the city and in the worst houses,” he wrote. Efforts to reduce health inequality focused on building a healthy community. The 1960s saw the establishment of community health centers, which were an outgrowth of the civil rights movement. These centers found some of their biggest champions in the Black Panthers, who regrettably are not commonly remembered for this legacy, said Dr. Maybank.
Today, the Health Department is “reinvent[ing] the old neighborhood health movement to meet the 21st Century, opening “neighborhood health action centers” in East Harlem, Brownsville, Brooklyn, and Tremont in the Bronx, communities with high rates of chronic disease, Dr. Maybank said. The department is motivated by the great health disparities in different New York City neighborhoods. The Health Department has offered visuals of these disparities in the “community health profiles," which map health statistics by neighborhood, using the extensive health data the city collects. For instance, four times the number of babies die in the first year of life in the majority African-American neighborhoods of Brownsville, Brooklyn, and Jamaica, Queens, compared with Greenwich Village. In the Rockaways the average resident lives 10 years less than those in Stuyvesant Town or the Financial District.
The neighborhood health action centers will bring community-based organizations and Health Department staff under one roof to provide, healthcare, wellness programs, space for groups to work on neighborhood health planning, and links to social services. The idea, said Dr. Maybank, is to move beyond the “traditional model of primary care which addresses individual health needs, to an integrated holistic and public health approach to primary care.”
Challenging the model minority stereotype of Asian Americans
The Asian American community has had to contend with a different type of discrimination, that of being thought of as the “model minority,” said Nadia Islam, PhD, assistant professor in the Department of Population Health. “The idea that they’re complacent, compliant, over-achieving and correspondingly without problems is both long-standing, and it’s also a persistent idea that rears its ugly head in the media,” Dr. Islam, who is also the deputy director of the Center for the Study of Asian American Health at NYU School of Medicine, said as she showed a 1987 Time magazine cover of an Asian American family with the headline “Those Asian American Whiz Kids.”
This notion that Asian Americans are a high achieving and healthy population can lead to them being ignored, said Dr. Islam. In fact, Asian Americans are actually the highest poverty group in New York City, as reported by the Office of the Mayor. Categorizing Asian Americans as one big model minority also ignores the “tremendous diversity” of the population and of their health. For example South Asian descendants, such as Bangladeshi and Pakistani Americans have higher rates of hypertension and type 2 diabetes than the general population, and Korean and Chinese Americans develop diabetes at a lower body mass index than the general population, making it harder to detect, said Dr. Islam.
City public health policies and guidelines that have led to overall improvements have not filtered down to Asian American communities, because of language and culture barriers, said Dr. Islam. Working to change that, the Center for Asian American Studies has built community coalitions with Korean & Filipino churches, South Asian mosques, senior centers, restaurants and grocery stores, to translate evidence-based prevention strategies, such as food standards and recommendations and a blood pressure monitoring program. The Center has then evaluated the effectiveness of their outreach, finding that after adapting New York City’s healthy food suggestions to Asian American cuisine, community members were more likely to try fruit, fresh vegetables, brown rice and lower salt condiments.
Changing the medical establishment's treatment of trans patients
As with Asian-Americans and African-Americans, prejudice toward and ignorance of transgender and non-gender nonconforming individuals has had a direct impact on their health, said Aron Janssen, MD, clinical assistant professor in the Department of Child & Adolescent Psychiatry at NYU School of Medicine. Focusing in particular on the medical establishment, Dr. Janssen said one in four patients have been kicked out of a doctor’s office when that patient expressed interest in gender transition, and 50 percent of transgender patients have had to teach providers about their own care. Trans health is almost never a part of medical school education, and the lack of data collected on this population is “horrific,” said Dr. Janssen, even though the number of trans people in this country is the same as the number of redheads and people with type 1-diabetes.
“When people talk about gender identity, people can dismiss it as this kind of Bay Area identify politics concept…[that] ’everybody’s a different gender now’…[and] this is a new cultural shift that people are creating out of nowhere,” he said. But in fact, gender ambiguity is not new. Although society perceives gender as binary, the reality is that one’s gender identity is a complex synthesis of birth sex, gender role, and sexual orientation that researchers like Dr. Janssen are still trying to understand.
In his practice, his number one priority is giving his trans patients the support they need, in order to prevent mental health problems that come from being marginalized. The transgender population has a 40 percent suicide attempt rate, said Dr. Janssen. “You wonder, as you look at these rates of suicide…what is the cost of internalizing this judgment? What is the cost of feeling like you have to hide this aspect of yourself?” he asked. “The number one factor that comes out in every single study and predicts good or bad outcomes for transgender folks is the support and acceptance of family. This by far when I’m thinking about what I do to treat transgender children, this is what I do: – I need to help families to love and accept their child regardless of what their gender is ultimately.”
Violence as a public health issue
Addressing one of the most heated race issues of today, an afternoon panel called “Is Violence a Contagion?” moderated by Rhonda Acholonu, MD, FAAP, associate dean for academic and diversity affairs, focused on efforts to treat violence as a public health problem that needs to be addressed preventively as opposed to an entirely reactive law enforcement approach. This is the model at the non-profit Cure Violence, which seeks to "stop violence at its source." “We go out to the community and distribute public education about how to reduce violence, interrupting and mediating conflicts as they take place on the ground level and identifying individuals at highest risk for spreading violence as you would someone who’s at risk for spreading a disease,” said Amy Wilkerson of Cure Violence. Lack of opportunities for education, healthcare, and jobs, are motivating factors, said Wilkerson. “What you want is a community & policy structures that minimizes those incentives and creates disincentives to be violent. If people are closed off to those alternative pathways, that’s when you see violence,” said Jeffrey Butts, PhD, director of the Research & Evaluation Center at John Jay College, who has studied Cure Violence. The program hires “credible messengers in the community," such as former gang and crew members, who identify and mediate potentially violent situations.
The role of a large healthcare system
If all of these community-based efforts seem removed from the healthcare system, they aren’t. NYC Health+Hospitals, the largest municipal public healthcare system in the country, is deeply focused on addressing the “social determinants of health” through its “performing provider system” OneCity Health, which includes 12 hospitals, 55 primary care organizations, and 250 partner organizations in Bronx, Brooklyn, Manhattan, and Queens including behavioral health providers, home care, nursing homes, peer educations, palliative care providers, and a “highly diverse group of social service providers,” said Anna Flattau, MD, MS, MSc, Chief Clinical Officer of the system. For example, OneCity Health is working on a $2.3 million program to bring together community members and social service organizations to address the household triggers of asthma, one of the top causes of hospital visits hospitalizations, and missed school days in New York City.
A midday poster session showed the wide range of health disparities research going on in New York City, covering topics like pre-exposure prophylaxis (PrEP) among men who have sex with men in London, hypertension among low-income housing residents in New York City, and the high prevalence of food and beverage advertisements in African-American neighborhoods.
Closing the symposium, Dustin Duncan, ScD, assistant professor in the Department of Population Health, noted that the work spotlighted at the symposium has an impact on real people: “While it’s easy to remember definitions, we need to remember these are people, not just data,” he said. “I hope this day highlighted to you the importance of the work you do, and the work that you want to do.”