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IBD Drive Time: Understanding the Social Determinants of Health
In this episode of IBD Drive Time, guest host Dr David Rubin and Dr Adjoa Anyane-Yeboa discuss how the social determinants of health--from race and income to government policies—affect the delivery of quality care to patients with inflammatory bowel disease.
David Rubin, MD, is the Joseph B Kirsner Professor In Medicine, chief of Gastroenterology, Hepatology and Nutrition, and director of the Digestive Diseases Center at the University of Chicago School of Medicine. Adjoa Anyane-Yeboa is an assistant professor of medicine at Harvard Medical School, a gastroenterologist at Massachusetts General Hospital, and a founder of the Association of Black Gastroenterologists and Hepatologists.
Dr David Rubin:
Hello everybody. It's Dr. David Rubin from the University of Chicago. And I'm guest hosting IBD Drive Time. IBD Drive Time is sponsored by the AIBD network, where we talk about inflammatory bowel disease and many of the topics that are important to all of us, and of course the people who live with Crohn's disease and ulcerative colitis.
Today our topic is on the social determinants of health and understanding health care disparities related to inflammatory bowel disease. And I have the privilege of speaking to one of my favorite people in the world, Dr. Adjoa Anyane-Yeboa, who is currently an assistant professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital. But I know her so well because she also did her GI fellowship with me at the University of Chicago. She received her medical degree from the University of Cincinnati, completed her internal medicine residency and a 4th-year chief residency at the University of Illinois in Chicago, and then came to work with us here.
After completing her gastroenterology training, she went on to pursue some additional training to further her drive to achieve equity and health outcomes for patients from vulnerable communities. She completed the Commonwealth Fund Fellowship and Minority Health Policy through Harvard Medical School where she also received her master's in public health with a focus in health policy from the Harvard TH Chan School of Public Health. So obviously highly qualified to talk about this topic.
Dr. Anyane-Yeboa is also funded by multiple grant agencies and works now specifically in the areas of IBD and also colorectal cancer screening and has been working in community health centers across Massachusetts. And importantly, she's a founder and board member of the Association of Black Gastroenterologists and Hepatologists, which she told me before we started today now has over 350 members. That's amazing, Adjoa. So thank you so much for joining me today for this really important conversation.
Dr Yeboa:
Thank you so much for having me. I'm really excited to be here. Good to see you.
Dr Rubin:
It's great to see you too. But of course, on a podcast nobody can see either of us, which is good because I didn't comb my hair. So we're going to talk about a few things, and I wanted to just start by asking a question that I think is really important to the background here, which is how did you get engaged in this particular space on health equity in medicine and gastroenterology?
Dr Yeboa:
Yeah, that's a really great question for context. So I've always been very passionate about diversity and health equity. And so just to kind of give us a little bit of context so we're all starting from the same place, health equity is ensuring that everyone has an equal opportunity to be as healthy as possible. And so for me, seeing individuals from historically marginalized communities time and time again, faring with worse outcomes from a variety of different diseases, oftentimes based on societal factors, is really disturbing to me and it's really upsetting to me. And so for me, it really comes down to justice and to fairness. And so I've really committed my career to leveling the playing field and ensuring, at least in GI, that individuals and our patients have the best opportunity to be as healthy as possible. And that's really what I'm devoted to doing every day.
Dr Rubin:
And you know that actually was something that I noticed about you but also has motivated me in my career— this concept of social justice. And one of the privileges we have in medicine, of course, is that we see people who come to us for their medical problems, but we have really the privilege of seeing people from all walks of life in many ways. And I think ideally, we all want to be able to provide the same level of care to people, but unfortunately it doesn't happen. So I suppose before we get into more discussions about social determinants of health and what that actually means, I wanted to start with just a definition of what is health—as much as we talk about it and everyone would like to be healthy, and we just celebrated New Year's Day and we say to people, I wish you a healthy 2024, at least that's what I say because I think that's the most valuable thing you can wish anybody.
I actually did some homework on this topic because I'm giving a lecture in Hong Kong next week on a healthy microbiome. And in the process of preparing for that and actually learning about disparities in microbiome, which might be another podcast, I read about the origins of a definition of health from the World Health Organization. So if you don't mind, I'm going to just read that out. Dr. Andrija Stampar from Croatia in 1948 said, "Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity." And it was later clarified further that health might be just defined as the ability to conduct a socially and economically productive life. You notice it doesn't even mention physical and mental wellbeing, because it's implied that you might need those in order to achieve the end or the goal of a socially and economically productive life. So Adjoa, I don't know if you want to add to that or what you think about that definition, at least from the World Health Organization and our approach to taking care of people.
Dr Yeboa:
Yeah, I definitely agree with the definition, and thinking about the factors that determine that health is really important as well, and the factors around an individual, not just in the clinic, but the factors that dictate their ability to do that on a day-to-day basis, I think are really important factors that contribute to health as well. And so I think that's a great definition, and there's a lot that goes into it.
Dr Rubin:
You were one of the first people to teach me about social determinants of health, which is why I immediately thought of you for this podcast. And I wanted you to teach our audience what that means. What does the term social determinants of health actually mean?
Dr Yeboa:
So the definition from the WHO—it's the conditions in which people are born, grow, work, live, and age, and the wider set of courses and systems that shape the condition of daily life. Some of these systems include our economic policies, development agendas, social norms, social policies, and our political systems. There's a lot that determines our health. And so these are our social determinants of health. And so when you think about our society and even our policies, our federal government has done things decades ago that still determine our health today. An example of that is redlining. The federal government through the Federal Housing Administration in 1933-1934, really led to the segregation of black individuals to less desirable neighborhoods through this process of redlining. And so this process has still led to the neighborhood segregation that we see today. And these communities still remain excluded from local and federal resources even 50 years after redlining was determined to be illegal.
And so it's really important to understand the context of the social determinants when we think about health. There are different factors of the social determinants or different examples of social determinants. We think about economic stability—whether individuals have access to gainful employment, to earn a living wage. We think about the neighborhood and physical environment— whether individuals have access to quality and safe housing, transportation, especially if we're thinking about making it to clinical visits, green space, whether they feel safe in their neighborhood, access to education, healthy food, whether they live in a food desert or they have limited access to healthy food or whether they have food insecurity where they're limited access to food in general. And then you think about the community and safety and social context, and of course the health care system, whether they have access to coverage, access to providers, pharmacies, providers that speak their language, and whether they're receiving high quality care.
And so those are all factors that are parts of the social determinants of health. And in addition, when I think about the social determinants, I like to think about upstream determinants like our policies, racism, immigration, sexual orientation, that impact midstream determinants like where individuals work, whether they have access to employment, where they live, whether they have access to food, access to the factors that allow them to live a healthy life. And then the downstream health outcomes like health disparities that we think of in a host of different diseases that result inequities in social determinants of health.
Dr Rubin:
So I think that it sounds obvious in some ways how differences in social determinants can lead to disparities, but it's not always directly related in that regard. So how do these things overlap and how might we use the definition and the different types of social determinants to better understand disparities? And then of course to address them.
Dr Yeboa :
Interestingly, inequities in the social determinants are intertwined with disparities and are intertwined with racial and ethnic disparities. And so when we think about communities that are faced with inequities in the social determinants of health and faced with inequities in basic measures of health status, it's the same marginalized communities that we see over and over again. So black individuals, American Indian, Alaskan natives, and Latino individuals over and over again are faced with inequities in the social determinants of health. And so there's studies looking at disparities in measures of health status, and we see that those communities fare worse on several measures of health status compared to white individuals. When we look at neighborhoods, we know that neighborhoods that are predominantly black actually have lower life expectancy than other neighborhoods. And that when you increase the percentage of black individuals in a neighborhood, that the life expectancy actually steadily decreases.
And so those are just basic measures of health status. But then when you think about, for instance, IBD, we think about these upstream determinants of policies that impact where an individual lives and whether they have access to even GI providers that they can get to easily or whether they have to take three buses to get to a GI provider. And all of those different barriers can lead to poor health outcomes downstream. And so the social determinants of health are closely intertwined with racial and ethnic disparities, and I think it's really important for our listeners to know that the social determinants of health are actually the main driver of health disparities. And so if we are wanting to impact disparities in health, we really need to look upstream at the social determinants rather than looking downstream after we already have disparities. And that's more so putting a bandaid on the problem.
Dr Rubin:
Right. And I understand how complex that is. I also certainly understand that it's a population—if you look at individuals that you've mentioned, those who are black or those who are indigenous Native American or however group you define it—they clearly have worse outcomes overall. How do you separate that from where they're living and their access as a group from the problems we have as providers or clinicians taking care of them and some of the biases that we may have in delivering care?
Dr Yeboa:
Yeah, I think there's many layers. And so I think there are the determinants, but then there's also the layer of the provider as well, and actually the provider of the health care system that's also a social determinant. And so I think it's really important for us as providers, and I hope I'm answering your question accurately, but it's really important for us as providers to understand our patients and to understand the challenges that they're facing and understand ourselves as well and our own biases. And so that when we walk into a room with a patient, we give them the best opportunity to be as healthy as possible. And that's whether understanding that their challenges with transportation are limiting their ability to show up to a colonoscopy or whether their challenges with time off work or child care are limiting their ability to come to their infusions. And so I think there's so many factors that are at play at one time, but I think understanding where our patients are coming from, but also understanding ourselves and our own biases and what we bring into a room with a patient is really critical.
Dr Rubin:
How does cultural competency factor into this? Is that something that is considered part of the provider's bias or ignorance in providing care for individuals of diverse backgrounds, or is that a separate issue?
Dr Yeboa:
So interestingly, cultural competency is also a social determinant, so there's many factors here. I think it's challenging because not all of us can know everything about everyone, but I think it's important to have a willingness and an openness in learning about where other individuals come from and understanding what they bring into the room with them when we're in a clinical visit with them. I think also one thing that is really critical, especially in cultural competency and linguistic competency is making sure that we have access to interpreters who can allow patients to ask the questions that they have and bring any concerns that they have to the visit and allow them to speak in the language that they're most comfortable in. And so I think sometimes we feel like, oh, I can speak a little bit of Spanish, but it's not enough for the clinical visit. And so making sure that we have all of the resources that patients need, whether it be linguistic resources or otherwise is really important.
Dr Rubin:
Yeah, I think that that's really important. I learned about a nice study that's being done in California supported by the Crohn's and Colitis Foundation, and I feel badly that I can't remember the investigator right now, but where they were studying specifically some of the barriers to adherence and successful care and IBD and something as obvious as language barriers were not being addressed enough that we were too often sort of fumbling through or having a limited translator access that could really impact the delivery and the subsequent follow-up of the care. We have enough trouble when we're speaking the same language, communicating about our goals and management and treatment options that we should certainly recognize this. But as long as you brought that up, let's talk about a few other positive things that we can do. For the people listening, what should they do the next time they're in clinic so they can start to address or understand perhaps some of their own implicit bias or limitations that they're experiencing in care? What would you suggest to them?
Dr Yeboa:
I think there's a few key things that we can work on. I think number one is in our clinical visits slow down. We're often rushed, sometimes running behind, rushing to the next meeting, rushing to the next patient. It's when we use our system 1 thinking or automatic thinking, that's when our biases come out. And so oftentimes when we're kind of relaxing, we're doing things in a more leisurely manner, we're thinking, I'm not biased, but it's really when we're under stress that our biases come out. So number 1, slow down. Number 2, know the biases that you bring into the room with a patient. And so taking things like the implicit association test can allow you to understand the biases that you have. And so when you're walking into a room with a patient, you can actively work to counteract those and knowing that maybe I have a bias against this community of individuals and recognizing that can allow you to actively counteract that. I think it's also really important to always ask patients, what matters to you? And so oftentimes what matters to us as the providers might be different than what matters to our patients. And so if patients are missing appointments or not coming in for colonoscopy, not taking their medication, really understanding, building trust number one, so they feel comfortable sharing this with you, but also understanding some of the upstream determinants that are impacting their ability to follow the treatment plan that you've set up with them.
Dr Rubin:
I suspect that people listening are thinking, sure, it's easy for them on a podcast to talk about slowing down when we all, regardless of which practice environment we're in, feel the pressure of time. But it certainly is valuable for us to take a moment to pause for a second and realize when we're under that pressure, where we might think it's going to be easier to just ignore some of the things that may be directing our care in biased ways. But you also mentioned something called the implicit association test. Is that what it was called?
Dr Yeboa:
Yep.
Dr Rubin:
So where might someone find that? Is that something easily found online?
Dr Yeboa:
Yeah, it's easily found online. I believe it's free. There's a host of different biases you can take tests for. I would advise to just look through and see what kind of speaks to you, but I definitely think looking at racial biases is definitely important. There's a whole host of different biases that you can find on the website, but I think it's just important to first search for it, see what speaks to you, and take as many as you can.
Dr Rubin:
Yeah, so I just looked it up while we're talking and there's obviously, this is probably the one you were talking about, but it's implicit.harvard.edu, and there's a whole bunch of information here as well as a test that people could take to see where their own mind might be because obviously implicit bias is not something that you're necessarily conscious of and you should, the first step is maybe understand some of that.
What about some of the other things that we might be doing to better understand how to address disparities? You talk about the upstream social determinants of health and where we might modify care, but can you comment on beyond the clinic, what else are we doing in terms of perhaps in the hospital system or at the level of industry in clinical trials as I think you know one of my other fellows and I looked at just the distribution by race and ethnicity of participants in phase 3 trials in IBD. And of course, up until very recently, it was almost exclusively white individuals. More recently, it's become some Asian individuals just because there's been a movement of our clinical trials to parts of Asia for recruitment purposes, but we still have a woeful disparity there as well. So what might you recommend or what should we know about that's being done to address some of these issues on a more sort of systemic and policy-based level?
Dr Yeboa:
Yeah, I think that's a great question. There's a lot of things that we should be thinking about broadly, and so there's different levels or layers that we can think about. The hospital system, like you mentioned, community industry policy, et cetera. Thinking about the hospital system, I think us as providers, we really need to be thinking about the social determinants at the point of care with our patients. And I also think that we should think about more different ways of providing care—meeting patients where they are. Oftentimes we wait for patients to come to us and they have to deal with the challenges of the parking garage, expensive costs for parking. And so having more GI and IBD providers in community settings, I think is critical to meet patients where they are. I actually do some of my clinical practice at a community health center just to play my part in being more accessible to patients.
I think another thing that you mentioned is clinical trials and increasing the diversity of clinical trials. I think the first thing that we can do is when we publish our trial is report. And so often if you look at some of these trials, they don't even mention the racial and ethnic distribution of patients that are included. And so I think in order to know there's a problem, you first have to report who you studied and who was included. I also think we need to be more creative in how we reach people again. And so thinking about how we recruit for clinical trials and maybe not doing things the way we've always done them, but being more creative in our approach in terms of reaching more diverse populations of individuals. I also think it might be interesting to partner with community organizations that have trust in communities of individuals that you can work with to build a bridge and where it's in a mutually beneficial way, patients can be identified and included in some of this important research.
The last piece I'll add there, too, is it's important for us as researchers and as providers to focus on building trust as well, because a lot of this stems from mistrust of the medical institution. I think one part of it is mistrust, another part is not being invited to conversations, but in terms of the mistrust, it's not something that will happen overnight. I think building trust takes years of work. And so we say, hey, we want to recruit more diverse individuals for clinical trials, but if you don't have trust in the community or have somebody, a partnership with somebody who does have trust as a voice in the community, then it's not going to happen. And so I think we really need to put the work in to build trust and know it's not going to happen overnight.
Dr Rubin:
And of course, starting with the next patient someone sees in their clinic, I think they should be asking themselves, is this an individual who in addition to the challenge of living with gastrointestinal disease and specifically to this podcast, Crohn's disease or ulcerative colitis, are they facing additional challenges in their care because of social determinants that are not in their favor? And I think that that's the most important takeaway message for folks to just open their eyes to this.
For those who want to learn a little bit more, Adjoa has published a number of papers on this topic. The one I of course will refer them to is one that we did together along with our colleagues Sandra Quezada and Sophie Balzora called The Impact of the Social Determinants of Health on Disparities in Inflammatory Bowel Disease. That was in CGH from 2022. I was going to say last year, but now it's 2 years ago. And I think that that's a really nice review of all this, including a Table 3 that summarizes different actions we can take and that our individual organizations and society can try to address some of these things.
I'll tell you that in my own practice of IBD, it's really striking when I see somebody whose diagnosis was delayed or who didn't get standard of care therapy in the right time or hasn't had access to some of the things that we would expect are really standard and should be available. And it breaks my heart when I see that. And so this is why this has become such an important thing for me to understand and to work on individually and to try to champion at a larger level. But you are really leading the way.
For those who want to learn a little bit more about the Association of Black Gastroenterologists and hepatologists, where can they go?
Dr Yeboa:
Blackingastro.org That's our website. They can also donate or they can join if they want to be a part of the movement.
Dr Rubin:
Amazing. Well, this has been a great conversation. I hope that it's helped our colleagues understand this topic a little bit more and then it's going to impact the care they provide to their next patients. I want to especially thank you, Adjoa, for being with us today. Dr. Adjoa Anyane-Yeboa is an assistant professor of medicine at Harvard Medical School and a gastroenterologist at the Massachusetts General Hospital. You've been listening to IBD Drive Time sponsored by the AIBD network. Thanks for joining us and sharing.
Dr Yeboa:
Thanks for having me.
