Considerations of Socioeconomic Factors in Health Equity

Among the most critical, seemingly underdiscussed aspects in the struggle for social and legal equity and equality is the fairness of health care systems when providing care for underserved and conventional communities. At the Cleveland Clinic’s recent health equity symposium, a featured panel comprised of several key opinion leaders discussed considerations and initiatives to bridge the gap of equitable care.

Karen Winkfield, MD, PhD, a professor of Radiation Oncology at Vanderbilt University Medical Center, Ingram Professor of Cancer Research at Vanderbilt Ingram Cancer Center, professor of Medicine at Meharry Medical College, and executive director of the Meharry-Vanderbilt Alliance in Nashville, Tennessee, imagines a re-envisioning of team structures in the workforce to become more inclusive. The challenge, according to Winkfield, is the identification of individuals from diverse backgrounds who also have the knowledge and skill sets to contribute to their respective teams. “I think it would be great to be able to say [that] we have benchmarks,” she noted. “But here’s the challenge: we want to make sure the individuals who are on the team actually have the expertise that is required.”

By this standard, Winkfield encouraged a modification in the definition of “qualified.” She stated that team leaders should be judged by more than credentials alone. “[The team leader] doesn’t always need to be a physician or an administrator,” she said. “There are real team leaders…right in our own institutions. But, because they don’t have a certain number of letters after their name, they are overlooked.”

NFN Scout, PhD, MA, the executive director of the National LGBT Cancer Network in Providence, Rhode Island; and vice president of Social Justice in Beverly Hills, California; echoed Winkfield’s sentiment. He highlighted the importance of using nonconventional methods when constructing health care teams to connect with specific patient populations that have unique needs when compared with those of the traditional community. Health care systems and providers now have a better understanding and recognition of specific health needs, yet the transgender community still needs advocates. Ultimately, this advocacy comes from a health care team’s strong understanding of the community’s particular challenges.

As a follow-up to Winkfield’s answer regarding the encouragement of creating benchmarks for diversity, Scout desires to instead view benchmarks as a minimum threshold. “As a White person leading an organization that is invested in diversity, and [with the] understanding that I’m representing a bunch of incredibly diverse populations that I could never fully understand, we try hard to make sure we reflect that in our employee team, because that’s the first step to doing any kind of good work.”

Mentorship programs were a key area of emphasis. Scout commented that individuals who have not had educational opportunities cannot thrive without mentorship. “You not only have to hire people who don’t have as many letters [after their name], but you also have to invest in that educational system to make sure that you’ve given opportunities.” Scout asked the audience to think about elite contributors to their health care teams and the inclusive opportunities that they were offered to develop their skill sets. He directly asked the audience what they are doing to “cross those borders to mentor some people” with whom they are less comfortable to be part of a future world envisioned.

Winkfield cited the aftermath of George Floyd’s murder in 2020 in her initial response. “There was a reflux in this country, and we’re already seeing that reflux wane,” she said. Although efforts such as this symposium give her inspiration and hope, Winkfield is discouraged by the slow progress of these endeavors. She continued, “I was hoping that the reflux that happened when [George] Floyd was murdered would actually do some good, but, frankly, I think we still have a long way to go.”

Vickie Eaton Johnson, MPA, senior director of Community and Economic Development and Local Government Relations at the Cleveland Clinic, agreed, expressing a sense of hopefulness. “There is a movement among the health care industry,” she noted. “In Detroit, where the congress has ended, there were CEOs of Trinity [Health System] and Henry Ford [Health], department leaders, professionals from all across the system” who presented the needs of patients having various demographics and coming from different communities. She is encouraged that top-level administrators heed the voices of the communities in need, pay attention to the expressions of advocates, and show particular interest in this progress on a public level. “I’m encouraged,” she said, “because people are showing up in places and having somewhat public, authentic conversations about how they’re holding their institutions accountable. [The goal] is to embed the work of equity [while] looking at social determinants of health.”

Scout is optimistic about the direction of this movement, but he is concerned about a potential backslide of these continued efforts. “Particularly because of the culture wars, by a lot of metrics, things are moving backwards in [the LGBT Queer and Other (LGBTQ+)] arena. I was co-chair of the 1993 LGBTQ march on Washington, [DC];…if you would have told me that we [wouldn’t] even have civil rights yet [at a national level], I would have said, ‘Are you serious?’” In contrast, Dr Scout’s optimism is rooted in the comfort level of youth who currently identify as queer, as he commented, “One of our historically attacked populations feels, at a vulnerable age in life, enough security to disclose [that personal information]. It is a very, very low bar, but it does help me think that that…some younger people are feeling more security in these underrepresented populations.”

Kim Bell, RN, MBA, executive director of Cancer Services at the Cleveland Clinic, emphasized the importance of building trust with communities in need through sustained community outreach and engagement efforts by health care systems. “You have to begin succession planning so that these programs stay in touch. When programs come and go within our communities, we lose trust.” A lack of sustainability can lead to a lack of confidence in the health care system among members of these communities.

Compliance in the health care setting is often viewed as a “yes or no” box to check. Is the patient compliant? Typically, this seems to be a rather straightforward answer. However, Winkfield desires to modify this terminology, removing the term “compliance” from language used in health care. She believes that this term facilitates a stigma that patients who do not adhere to treatment are uncooperative. In reality, the patient population is comprised of individuals who have their own unique set of circumstances and challenges in life. An unanticipated stressor, such as losing a loved one, can provide additional mental and emotional hurdles that can make therapeutic adherence more daunting. Ultimately, treatment compliance should involve the use of therapies that consider patient tolerance and thresholds to optimize outcomes and quality of life. Unfortunately, external factors and stressors of daily life exacerbate the burden of disease and its treatment.

In Winkfield’s view, patient compliance should be a conversation rather than a response evaluated on a “yes-or-no” system. “What I [see] is our patients keep being labeled as noncompliant. That should be removed. Now, should we have compliance? Yes, there are things we need to do organizationally to meet our metrics, etc. But the thing I’m specifically talking about is the labels that we use to describe patients who may not be doing what we think they should be doing instead of having a conversation.”

The distrust that exists in underserved communities has existed for decades, leading to necessary, life-saving treatments being avoided by individuals in need of critical care. These concerns were not generated de novo. Instead, individuals who have experienced their own traumas while in the trusted care of providers are scarred; they feel safer when battling life-threatening diseases independent of appropriate and necessary medical management.

Through her tenure with Cleveland Clinic, Johnson has engaged in many efforts to expand community housing programs in the Cleveland, Ohio, area as the hospital system grows. Initiatives that include Cleveland Clinic’s partnership with Habitat for Humanity can provide a genuine impact within the community. With continued awareness, advocacy, and resources, health care systems and their currently underserved communities may soon enjoy a self-sustaining, trusted relationship.

KIMBERLY BELL, RN, MBA

Executive Director of Cancer Services

Cleveland Clinic Health System

Cleveland, OH

VICKIE EATON JOHNSON, MPA

Senior Director

Community and Economic Development & Local Government Relations

Cleveland Clinic

Cleveland, OH

NFN SCOUT, PHD, MA

Executive Director

National LGBT Cancer Network

Providence, RI

KAREN WINKFIELD, MD, PHD

Executive Director, Meharry-Vanderbilt Alliance

Professor of Medicine

Meharry Medical College

Ingram Professor of Cancer Research

Vanderbilt Ingram Cancer Center

Professor of Radiation Oncology

Vanderbilt University Medical Center

Nashville, TN