ESTEBAN: Well health equity is really the opportunity for everyone to achieve their highest level of care. The converse of health equity is health inequities and so we see that in the population there’s variety different health equities meaning that not everyone has that opportunity either because of social constructs or oftentimes unjust factors that have precluded them from getting their highest level of care.

DAN: So give me an example I think I think this is one thing that would really benefit from describing maybe a persona of differences in health equity.

ESTEBAN: Well you mentioned it earlier is that equal care is not the same as equitable care. So I can as a physician prescribe everyone who has a certain diagnosis the same treatment. However let's say you don't have transportation to go to the pharmacy to pick up that that prescription or you don't have the language skills to really understand or ...

DAN: Can afford it

ESTEBAN: ...you can't afford it. That's not equitable care. Again there are variety different issues that occur based on people's race, ethnicity, gender, LGBT status that might preclude them from getting their highest level of care. And so the idea is to make sure that we're providing equitable care and identifying those inequities oftentimes related to social determinants of health. The social determinants of health are those factors in your life that affect your care such as your education, your income, the zip code that you live in, things to that effect.

DAN: So it's kind of a different way of looking at things right because we tend to focus primarily on well if you can afford it then or if you've got health insurance then you're fine. But actually it's you're telling me it's more complicated than that.

ESTEBAN: It's a lot more complicated. I can give you a personal example. You know I grew up in Los Angeles and my mom is, my parents are immigrants from Mexico. I never miss school growing up. But the one time that I did miss school was because I had to take my mom to the doctor we had to take two buses. So I remember walking a mile. My mom didn't drive. She does speak English. And so I'd walk a mile to the bus stop with my mom we'd take two buses we'd get to the doctor's office, Behind the curtain I wouldn't be interpreting at 9 years old for my mom. That's not the best health care. And but that's very common my story is not unique. So clearly my mother suffered from health inequities in the sense that she didn't have proper interpretation. She had to face a variety of different challenges to get to the doctor's office. Clearly they didn't have that, my mom worked in a factory so they didn't have a network that was open after hours or on the weekends. Her child had to miss school for her to see the physician. She never missed work, I rarely miss school. But in those instances that's why they're kind of ingrained in my mind. I still remember the bus number that we would take.

ROSS: So access was is not always necessarily equal for you as it would be for somebody else. Dr. Thankavel you’re pediatrician right by trade, maybe you could share some experiences that you've encountered as a doctor.

BHARATH: Yeah absolutely I think in pediatrics it feels like it's even more vulnerable population right. And we do remember that you know parents are well-intentioned and they really want to do the right thing for their for their kids. And so sometimes in the 10 years that I practice it might often see asthma as a pretty common problem. And people feel like they understand generally how to manage asthma. Right so one of the basic ways is to use an inhaler and you can have in an equal practice of physicians prescribing the appropriate medication or inhaler to a family but oftentimes I would see families come in with kids having severe asthma exacerbations and you could treat them and they'd feel better. And here they are on the way to go out the door and we would forget to ask those last few questions about why that child really was in that state. Is it because their asthma was difficult to control or was it because the family potentially didn't have the ability to pay for that medication. And I got to think it's not that the parents don't want to pay for that medication who doesn't want to pay for medication for them for their kid? Its that they've got competing interests do they want to pay their rent that month. Do they want to pay for food that month or they want to pay for their medications and again most of us would say well it'd be the medication. But if you've got an illness that's intermittent you're going to hedge and say well maybe my child won't have an asthma attack this month and I can actually pay for the rest of my life and it's us having to meet that that gap and really solving for those problems for those patients and families that's gonna make a big difference and that's a huge social determinist

DAN: Let me ask your question so do you think the health care system today is really trained and educated on managing these factors related to health equity.

ESTEBAN: No. So, asthma’s a perfect example I'll continue that conversation. So let's say that same child lives… is lower income and lives in poor housing stock. So a higher

DAN: Okay so I'm sitting here though on the podcast with two experts when it comes to health equity and what's the average training, are most physicians aware of these issues on health equity. Are they, are we training physicians that know how to manage it. I know the system itself needs improvement but I mean are we even able to identify these typically in an office and address them.

ESTABAN: I would say that most physicians understand that their patients suffer from a variety of challenges that prevent them from getting at their highest level of care. I worked on the west side of San Antonio when I was out of my residency at the Texas Diabetes Institute and 80 percent of my patients were complicated diabetics, people living with diabetes who were of low income. I was lucky if they had something like Medicaid. A lot of my patients had no insurance. So we worked double time to make sure that they were getting medications and trying to address their issues. However physicians, most physicians practices including my own were not set up to be able to do that.

DAN: They were set up to actually intervene and execute on maybe some of the improvements that needed to be done.

BHARATH: Yeah and if I could add I think that's you know once you were an attending physician having your own practice right. That's one thing but what about medical students or residents who have no formal training or understanding that there should be a part of the way that they evaluate a problem that they're being faced with with taking care of that particular patient right. That's not even there and so I'm to learn it on the fly when you're practicing you're able to do that but it's not the most efficient way to do that you're not starting with a strong base to understand how to actually move the needle and I think that does people a real disservice.

ESTEBAN: And I think that I didn't even know the term health equity when I was in medical school residency I didn't learn it until years afterwards. I understood that there were problems but I didn't understood that there was understand that there was a term that addressed it. So I think being able to educate more medical students residents on what health equity is and what health inequities are a great example is a negative birth outcomes in black women both from a maternal mortality perspective and an infant mortality perspective. We're taught that we know that that occurs right but we're never really told why it occurs. And so it has to do with health inequities within the black population. The leading public health hypothesis is that the those health inequities are due to the effects of racism. So either implicit racism, the fear of racism or overt racism that occurs within that population and the stress that that causes, causes real physical changes in both mom and baby, increasing cortisol levels, basal constriction of the placenta which leads to antimurine uterine growth retardation. All of these things but most of us then think oh it's genetic when indeed it's not. You know we see black women who come from Africa or the Caribbean have birth outcomes equal to the white population and then in one generation their daughters have birth outcomes equal to the general African-American population.

DAN: So it's always I think challenging in these kind of discussions to pull one thing out. Right. Because this is a very multifaceted challenge. But, but as someone who leads the health plan in a state with radically changing cultural demographics. What effect is cultural competency have on on health equity?

BHARATH: I think it has a huge impact. I think that's one of the first things that you know anybody in health care especially docs or anybody that's working in a practice needs to fully appreciate and be trained on. And I think that starts with just being, open your eyes to the fact that people are different and it's OK and we all have different problems. But physicians need to understand that it's like you're trained to tackle very direct medical condition. Got to understand that there's other parts to the person right. And part of that is their culture, their background, their experiences and how do you meet them halfway. It's not enough to just give like we talk about like equal care it's equitable care by understanding that they're different people and cultural competency is part of that. So how do you expose docs to different ways of understanding people.

DAN: So here's a hard here's a hard question for you and you may not be able to answer but I'm gonna throw it at you anyway so you said “Teach”.It looks like to me that that recruiting and and bringing in people from these communities and areas would also help because there's an innate understanding of this competency and the inequities that are occurring in that community. You think we're doing a good job today of recruiting health care providers, physicians and nurses and the whole system that's diverse enough to be able to understand these issues that are so complex.

ESTEBAN: No. So Texas is roughly about 42 percent Latino and the physician workforce is last time I checked was about 8 percent. And we've had we've been stagnant at about 10 percent of medical school...

DAN: So that's just one variable along Right?

ESTEBAN: Sure.

DAN: But it's still pretty significant percent.

ROSS: 8% Latino and then the overall population represents what?

ESTEBAN: Roughly 40 to 49 percent

DAN: So let me, Bharath, let me ask you this question. So if we just talked about the fact I and I think all of us maybe except for Ross, we all went to medical school, we all probably had a pretty similar education and training. I can honestly tell you that I never took a class at all on health equities, course I'm older and back in those days the anatomy was just being discovered when I went to medical school but here here's the story. Well if you're a physician and you're watching the podcast today how do you learn about health equities in what you can do and what resources are available particularly in the challenging pace of running a physician office which are right now many primary care physicians who are on the front lines of these kind of health equity issues are challenged to keep their doors open. So how do we learn and become part of the solution?

ESTEBAN: Well there's a variety of different channels online is one great example. The Americans, I believe it's called, the American Academy of Public Health or the National Public Health Association I can't remember the exact name they have referred.

DAN: We'll put the link on.

ESTEBAN: They have great articles on on health equity and health equity has gotten a lot more attention over the last several years. And we we've been talking about it for a long time but there is a wealth of information online with regards to health equity. It's important for providers, physicians who are scientists to understand that there are underlying causes to the differences in the health outcomes or how their patients interact with the health care system. And there is a science behind that and there's reasoning behind that. And that way we can then start addressing those issues and make sure that we're allowing our patients to achieve their highest level of care.

DAN: Well I can say this I've learned a lot about health equities today. So thanks for being here. We've got more coming up. Thanks for joining us for this segment of Blue Promise and thanks for listening.