… and Justice for All: Advancing Health Equity in Michigan

“We are living through an unparalleled time that has laid bare significant gaps in health equity in many communities across the state. [These communities] are much less healthy, less safe, have fewer opportunities for jobs, are more likely to be food deserts, and have poorer access to health care than many other communities in the state.”
Theodore Jones, MD, Wayne County, Chair, MSMS Task Force to Advance Health Equity

For S. Bobby Mukkamala, MD, Genesee County, a simple drive home from the office was all it took.

“I saw a billboard on I-75,” he says. “It showed the average life expectancy for a person living in the city of Flint compared to the next zip code over, in Grand Blanc. The billboard pointed out that people in Grand Blanc live, on average, 20 years longer than people living in Flint. That’s two decades, just based on adjacent zip codes—and it really hit home. It was at that point I really started digging into what was going on in my community from a health equity perspective.”

Doctor Mukkamala’s investigation quickly led him to one inescapable conclusion: there are cracks in Michigan’s health care system, and those fault lines center around unequal outcomes among various patient populations.

“Despite our best intentions, there are significant health disparities here in Michigan,” Doctor Mukkamala says. “It is a high priority for us as a community of physicians to consider and address very carefully, so each patient receives the best care possible, no matter who they are or where they come from. We saw the issue brought suddenly and sharply to light during the COVID-19 pandemic, which was in many ways the biggest wake-up call yet for physicians, health care systems, and policy leaders alike.”

Health equity is a challenging topic for many physicians as professionals—and, indeed, as Americans—living in the year 2021. Issues related to race, gender, income, age and ability are tough conversations for our society today, with dialogue that can be loaded with generational trauma, acrimony, fear and guilt.

But, as the events of the past year have shown, they are among the most important discussions we can have. That is why the Michigan State Medical Society has launched a new task force to Advance Health Equity to conduct extensive, thoughtful statewide conversations on the topic.

Specific strategies to be pursued within the Strategic Plan’s structure include:
The development of strategic partnerships,
Education and resource development,
Legislative, regulatory and payer advocacy, and
Health equity prioritization

This new task force, chaired by Theodore Jones, MD, is dedicated to exploring strategies for eliminating health disparities among populations across Michigan.

“As a medical society, we need to really be concerned about the health status and care experiences of all state residents,” says Stacey Hettiger, senior director of medical and regulatory policy at MSMS, who is providing staff support for the task force. “As we think of the current inequities that exist, it’s about more than implicit bias, though that’s certainly a piece of it. It’s also about social determinants of health and the larger institutional factors that create adverse outcomes for people.”

It’s also challenging territory. Conversations about health equity are uncomfortable under the most positive of conditions, for they reflect shortcomings in a system from which our society expects a great deal.

“These discussions are going to require a lot of self-examination,” says Lawrence Reynolds, MD, Genesee County, a pediatrician from Flint. “Some people, when they realize they’ve been doing something that is perpetuating an inequity, are overwhelmed by guilt. And people respond to guilt differently, particularly when it comes to their own biases. Some seek to make amends, some will try but then quit early, and others will just say, ‘it’s your fault, not mine.’ And then there are other folks who say, ‘Why don’t you all get over it’? We have to be ready to address all of these reactions in ways that make sense and lead to better outcomes.”

Doctor Mukkamala concurs.

“This is an important topic, and we need to handle it the right way,” he says. “We need to use approaches that are deep, respectful and strategic, so we don’t have unproductive conversations that feel defensive or divisive. Our dialogue needs to meet people where they are so we can change the aspects of our system that aren’t working to ensure equitable results for all patient populations.”

The Challenge

Health disparities have been a topic of concern since the mid-19th century, when social and medical experts first began to recognize the different experiences and outcomes of different population groups. After World War II, both the World Health Organization and the United Nations’ Universal Declaration of Human Rights enshrined the health equity concept as an ideal to be pursued.

For many years, however, the issue has been simmering beneath the surface of a global conversation that’s been more focused on emergent situations. In fact, health equity has seemed to be such a distant ideal that most felt it probably could not be achieved in anyone’s lifetime.
With the advent of COVID-19, however, the need for more equitable health outcomes was cast into stark, immediate relief. Here in Michigan, for example, COVID-19 cases among Black and African American populations were, on a cumulative basis, 40 percent higher than among white populations. Similarly, Black and African American deaths due to COVID were more than three times the rate among their white counterparts.

“COVID-19 showed us the scope of the problem in ways that were vivid and urgent,” says M. Roy Wilson, MD, president of Wayne State University and appointee to the Michigan Coronavirus Racial Disparities Task Force. “If you were going to get sick or—God forbid—die from COVID, it would happen in days or weeks rather than 10, 20 or 30 years, as in other chronic diseases like diabetes or hypertension. And so it really focused attention on this immediate problem, while giving us an opportunity to think deeply about how we can address our state’s health inequities more broadly in the future.”

From maternal and fetal loss at the beginning to life to sickle cell disease, HIV/AIDS, cancer, diabetes, lung disease and stroke, adverse health outcomes are more common among Michigan residents who are Black. Given that these illnesses and conditions take so much time to manifest, however, there was little urgency around addressing them in all populations.

The health equity challenge is even evident in today’s medical research.

“I was just reading that almost nine times more is being spent on cystic fibrosis research than is spent on sickle cell disease, even though sickle cell disease is three times more prevalent,” Doctor Reynolds says. “So it’s a history of decisions, practices and allocations of resources that contribute to health disparities and move us away from a place of equity.”

Doctor Reynolds says these kinds of disparate outcomes have their roots in institutional racism.

“If you start with the premise that one group of people is not entitled to the same protections as others, it quickly becomes a practice,” he says. “And although its roots may not be apparent to later practitioners, it’s the assumption, ‘Oh, well, we’re doing all this research in, let’s say, cystic fibrosis and so I’ll do some more.’ Your mentor will have you go into that area. The dollars will follow the more experienced researchers. So it’s one step after another, to the point where the researchers, the practitioners, the funders become blind to this inequity and just don’t see it anymore.”

Of course, these disparities and implicit biases are not confined to issues of race.

Moreover, there are structural inequities present in health care systems, from research and policy to affordability and access. There are widespread differences in the social determinants of health that also foster outcomes that are less than optimal for everyone.

“We’ve barely begun to scratch the surface of all the interconnected systems that result in disparities among Michigan residents,” Doctor Reynolds says.

The Opportunity

For Brian Stork, MD, Muskegon County, the journey toward health equity in Michigan is paved with awareness.

“Everyday, before I begin surgery or clinic, I make an effort to ‘get my mind right’ by reflecting on my own biases, thinking about where they came from, and making an attempt to filter them out,” he says.

Doctor Stork grew in his own awareness through past work with a Muskegon organization that helps young adults aging out of the foster care system.

“Working with this population of young adults, we quickly began to see differences. We went on to learn about how exposure to childhood trauma can lead to dramatic changes in behavior as well as physical, and mental health,” Doctor Stork says. “Over time we began to understand, more and more, that when people don’t have their basic needs met, there’s a domino effect in terms of their health. As physicians, each one of our interactions with these vulnerable adults is a potential game changer. We can’t afford to let any personal biases get in the way.” The key, Doctor Stork says, is ensuring we don’t lose focus and urgency around the need for health equity in Michigan.

“We’ve gained a lot of knowledge from the Flint water crisis and from the COVID-19 experience,” he notes. “The topic is right in front of us, right now. The challenge will be to keep it right there in front of us when these crises have passed.”

According to Doctor Reynolds, that day is still a long way off.

“Many people think it’s over,” he says. “But I am a Flint resident, who drank the Flint water, who worked in Flint during that year when no one would listen. I’ve been on the work groups and coordinating committees and task forces—and we’re still a long way from achieving justice. It’s a crisis that keeps on cursing us to this day.”

The same was said of Michigan’s COVID-19 experience during the early days of the pandemic.

“Our state had its residents who were Black going to the emergency rooms and being turned away, so they would go back home and die,” Doctor Wilson said. “They were dying at four times what the expected rate would have been. And the other part of it was a reduced access to testing, because you needed to have a car to get to many testing areas. Mobile testing was needed to get to the populations that were most vulnerable.”

These issues were addressed though the concrete actions taken by the Michigan Coronavirus Racial Disparities Task Force. Doctor Wilson says the work made an enormous difference, and gives him hope for MSMS’s future task force discussions.

“Our work wasn’t just theoretical,” Doctor Wilson says. “I am convinced our efforts actually helped eliminate the gaps among populations who were contracting and dying from COVID-19 in significant ways. There was a measurable outcome at the end of all that, which makes me think that having a task force for eliminating health disparities more broadly can lead to some major improvements.”

The Future

When it comes to having a productive, positive conversation of health equity issues, the road ahead is murky. Health care professionals are, by virtue of the careers they have chosen, caring individuals who want to help people remain healthy and disease-free. They are well-educated and thoughtful, so the implication that their work (and the systems that have been built to support it) can often result in adverse outcomes for some groups of patients—well, it stings. A lot.

Add the ever-changing complexity of modern American language, the turbulent 21st-century political environment, social media and the possibility of reputational harm, and the prospect of a deep statewide discussion of health equity can seem worrisome at best, frightening at worst. What if I choose the wrong word and offend someone? What if someone suggests I’m racist, ageist or anti-feminist?

And, most of all, how can we move forward productively in ways that are specific and concrete enough to generate the results we hope for?
“First of all, I think we need to go slowly,” Doctor Mukkamala says. “People need to feel safe in order to be honest, and that requires a high level of trust. We need to gather input from people who are more ‘woke,’ and from others who think this entire exercise is a waste of time. Both perspectives have value, and both need to be accommodated in ways that make it more comfortable for them to talk to one another.”
Hettiger also makes it clear implicit bias isn’t the only topic on the table.

“There are so many other aspects to health equity, and those factors need to be discussed as well,” she says. “We have to look at the social determinants of health across Michigan, and how we can work together to make a difference in these areas. We have to think about medical deserts, where people can’t access the care they need in a timely way, and are suffering adverse outcomes as a result. We must consider the policies—from payers to statewide policy—that impact public health. There are so many levers we can press to improve health equity in Michigan and, through this work, we’re putting them all on the table.”

Some physicians, like Doctor Reynolds, are eagerly anticipating the work ahead.

“I can’t wait for things to change,” he says. “Is it better than it was before? Yes, but we still have a very long way to go. We need to listen when someone says, ‘Hold up, this doesn’t look right, sound right, or smell right.’ We have to change the power dynamics, broaden our perspectives.”

Doctor Mukkamala agrees.

“I’m really excited about the fact that we’re moving in this direction,” he says. “It’s a turn in the conversation that has needed to happen for a long time, for our state and for our entire nation. The most important thing I can say to my colleagues in the medical profession is that this is not something that any single one of us is to be blamed for. We are all human beings, and this system wasn’t built by any person or group in isolation. Together, we all have an opportunity to grow and to change the system for the better.”

As the MSMS task force comes together throughout the rest of 2021 and beyond, it is important for all society members to find ways to add their voices. Whether it’s participating in a stakeholder meeting, providing advocacy locally or at the state level, or collaborating to increase access, there are important roles for all those working in Michigan health care to play.

Of course, it all begins with a personal commitment to being part of the process. If you are interested in becoming involved in MSMS’ work on health equity, contact Stacey Hettiger at SHettiger@msms.org or call MSMS at (800) 352-1351.

We all rise and fall together,” Doctor Stork says. “As health care professionals, as hospitals, as governments and payers—we want everybody to do well. With that as our goal, how can we go wrong?”