Alberto Moreno, executive director of the Oregon Latino Health Coalition, launched the Oregon Health Equity Alliances’ Oregon Equity Project session with what he called a “radical idea”: that all should have “unabridged access to healthcare” and the “best culturally competent care possible.”
Social determinants – income, education and race – have long been linked to health outcomes. “It’s not new ideas. It’s listening to what the community has been saying,” said Tricia Tillman of the Oregon Health Authority’s Office of Equity and Inclusion.
To achieve true health “equity” – not just equal health care – Tillman is pushing for healthcare reform to include culturally and linguistically appropriate service and to integrate community health workers, doulas and other “traditional health workers” into care teams.
“I’m a community health worker top to bottom, the street to policy,” said Lakeesha Dumas, who described the type of service she provides as going beyond the patient to the larger family. For example, one woman in Dumas’ care had mental health and addiction issues. Dumas made sure the woman’s children got wellness exams and engagement with Alateen. “Many kids have never had a checkup,” Dumas said. “Their only interaction with doctors has been in ER.”
But social determinants can impact health long before children are born – and late in life. Tillman cited an OHSU researcher who found that stresses in the womb impact a person’s health much later. Maternal exposure to poor housing, unemployment and other stresses can impact that baby in the form of heart disease, osteoporosis and diabetes. “It’s really about what was going on with your mom when she was pregnant with you,” Tillman said. “And your mom’s mom.”
Dr. Brian Smedley of the Joint Center for Political and Economic Studies in Washington, D.C. also urged people to “think about root causes and don’t shy away from hard conversations on race and racism.”
Smedley quoted a study on the role of segregation that compared apartheid South Africa in 1991, where 90 percent of the country’s whites and blacks would have needed to move to integrate that country, to major cities in the U.S. in 2010. In Detroit, 85 percent of that city’s population would have had to move to integrate. At least 80 percent would have had to move in Milwaukie, New York, Chicago and Newark in 2010.
“Segregation concentrates poverty,” said Smedley, with the poorest communities lacking access to good schools, jobs, healthy food and better returns on real estate investments. But he cautioned against some place-based strategies to combat poverty due to the danger of gentrification. “When you make a place nicer, the rich move in.”
Housing mobility can be a better alternative, he said, creating true mixed-income neighborhoods by using vouchers to move people out of the poorest neighborhoods and into neighborhoods with better schools and other infrastructure -- including access to healthcare.
Even though many who have not had insurance in the past now have enrolled in coverage, Smedley asks how likely they are to live in a community with adequate geographic access to primary, dental and behavioral healthcare.
Tillman reminded her audience that this is a “hugely emotional topic,” and people shut down when confronted with white privilege. Tillman said discussions of health equity bring up fear, anxiety and guilt.
Tillman told the audience they need “informed consent to start talking about health equity knowing those conversations have risk – just like any medical procedure.”
Jan can be reached at [email protected].