The Bronx is Not Underserved: Unconscious Bias Puts Patients Second in Disadvantaged Communities
With the poorest urban congressional district in the United States, the Bronx has long been held as representative of the challenges, and consequences, of health inequities. It should then come as no surprise that the Bronx has been especially hard hit by COVID-19 since, for the last seven years in a row, it has been deemed New York State’s “unhealthiest” county in annual rankings by the Robert Wood Johnson Foundation (RWJF).[1]
However, the Bronx is far from “underserved”: there are 9+ advanced teaching hospitals, an internationally renowned medical school, and more than 4,000 physicians who work within in its 42 square miles[2] (and that’s not counting all the nurses, pharmacists’, therapists, and social workers). That’s one provider for every 350 of its 1,400,000 people; almost 100 physicians per capita for every square mile. With all that clinical firepower, you’d think we could do better; yet the Bronx has remained vulnerable and unhealthy.
The same is true for Pittsburgh, where a 2019 report on gender and race inequality found that Pittsburgh’s rate of infant mortality for Black babies is more than six times higher than it is for white babies, and people of color have a higher prevalence cardiovascular disease, cancers and a host of other adverse outcomes, including premature mortality.[3] Yet Pittsburgh is far from underserved; between the two major health systems, UPMC and Allegheny (which together generate more than $25 Billion in revenue), there are over 48 hospitals in the region and more than 7,000 employed physicians. While many of those physicians may be hospital-based specialists, it is enough for one doctor for every 400 of the 3,000,000 people in the 28-county Pittsburgh megaregion and one for every 250 people in the five-county region surrounding Pittsburgh proper.
There is ample evidence that health status of a population affects economic vitality directly through enhanced labor productivity and reduced burden of illness on individuals and families, but also indirectly through the impact that health has on educational opportunity.[4],[5] If this is the value of a healthy community, what’s kept the Bronx’s “last place” streak going for seven years?
Despite their longstanding commitments and contributions to community health improvement initiatives (UPMC cites $1.4 Billion in ‘IRS-defined community benefit’ for 2019) , the fact is that large health systems, which often control a significant amount of care delivery in disadvantaged communities, have an existential conflict between the needs of the community and the needs of the institution: Organizations like the Bronx-based Montefiore Medical Center and its affiliated medical school generate a proportion of their $6.2 billion in annual revenue and research funding from the economic value of preventable illness and vulnerability of the community. Shouldn’t some of the ‘value’ of that investment be measured by community-level outcomes: are we unintentionally shaping our investments in the health of hospitals over the health of their service areas?
In engineering, a ‘fail-safe’ is a downstream feature of a system that is designed to minimize harm associated with some form of upstream system failure. Fire-sensitive sprinkler systems are a good example; while our primary goal is to prevent fires from occurring in the first place, the sprinklers are there to mitigate the consequences of a failure of fire prevention efforts.
Unfortunately, our healthcare system is designed around the fail-safe model. As a nation we are weak at improving health, but excellent at managing our own upstream failures, as evidenced in the remarkable response of our systems of care to our nation’s inability to contain COVID-19; treating sick people remains a very valuable thing to do, so there is little incentive to organize our systems of care beyond biomedical or biomechanical interventions.
The biggest barriers to improving the quality of health of communities like the Bronx are the continued dominance of the “fail-safe” biomedical model[6] and the profound consequences of health-related social weaknesses, especially those we have chosen to ignore, such as systemic racism, social determinants of health, inequitable access to care, and deficient scientific literacy. This introduces unconscious bias into organizational decision-making: people need to be sick for most healthcare organizations to be successful; a truly healthy community could threaten their existence.
Even recent interest in ‘social determinants of health’ is driven by economic incentives associated with managing utilization of hospital-based services by individual patients, not the upstream socioeconomic and educational inequities and systemic racism that are the root cause of those determinants and undermine the vitality and health of our communities. Building an addition on the house of medicine does not change its foundation.
Instead of access to care, perhaps it is time to consider “quality of health” as the social imperative of our systems of care, focusing on the value of health to support and improve the capacity of individuals to succeed in the world on their own terms and contribute as active, productive members of family and community. This would become the basis by which we determine the requirements for our model of care and its associated systems and define the metrics for return on investments intended to improve the health of our citizens.
Most of the tens of billions of dollars spent on medical care to the citizens of the Bronx, and communities like it, comes from government — City, State and Federal — coffers, but are parsed among many dozens of institutions such as hospitals and health systems, managed care plans, community health centers, and group practices that traditionally operate under a respectful compact of mutual self-interest, but do not genuinely collaborate.
Unfortunately, in healthcare, even when everyone is at the table (or facing the patient for that matter), collaboration is often is no more real that the parallel play of toddlers. Upstream transformation towards a tangible improvement in quality of health of individuals and communities will only work if all share the belief that the benefits of collaboration will offset the loss of autonomy and “turf”, or even some venerable institutions.
Genuine collaboration will require government to shift from their existing, fragmented, investments to a ‘whole-person/whole-community’ economic model, and require orchestration of health, educational, and social services resources towards community-level goal achievement, where objective measures of health status — such as the RWJF County Health Rankings or Pittsburgh’s Index of Ranked Livability — are the gauges of success and payment.
Under the social imperative the traditional biomedical perspective will become subordinate to a person-centered definition of health, driving new, non-categorical approaches to how we assess and intervene to improve the health of individuals and communities.[7],[8] However, we also need to be aware that the same unconscious bias that drives institutional self-preservation will provoke desperate attempts to achieve equilibrium — when equilibrium is impossible and change unavoidable — that can impede evolutionary progress. The fact is that if we are successful in our social imperative for health, many of our current institutions, resources and roles may become superfluous.[9]
It’s time to organize our resources towards a collective leadership strategy to protect, and improve, the health and well-being of the multicultural Bronx and similar communities around the country. With full recognition of the acute and intensive care challenges facing hospitals and health systems due to COVID-19, City, State and Federal government should shift their focus to supporting collective accountability as the basis of the road map and incentives for geographic population health, and finally address the persistent barriers to achieving the social imperative in communities disadvantaged by economic and social inequities: let’s stop the parallel play and come together to put people and community first.
REFERENCES
[1] Robert Wood Johnson Foundation. County Health Rankings and Roadmaps. 2020 Rankings.
https://www.countyhealthrankings.org/app/new-york/2020/rankings/outcomes/overall. Published March 10, 2020. Accessed June 30, 2020
[2] New York Public Interest Research Group. The Doctor Is In: New York’s Increasing Number of Doctors. https://www.nypirg.org/pubs/health/2014.08.21DoctorIsIn.pdf Published August 21,2014. Accessed June 30, 2020.
[3] Howell, Junia, Sara Goodkind, Leah Jacobs, Dominique Branson and Elizabeth Miller. 2019. “Pittsburgh’s Inequality across Gender and Race.” Gender Analysis White Papers. City of Pittsburgh’s Gender Equity Commission.
https://apps.pittsburghpa.gov/redtail/images/7109_Pittsburgh's_Inequality_Across_Gender_and_Race_09_18_19.pdf Published September 17, 2019. Accessed June 30, 2020.
[4] Lopez-Casasnovas G, Rivera B, Currais L (ed.), Health and Economic Growth: Findings and Policy Implications. Cambridge, MA: MIT Press (2005)
[5] Blue Cross Blue Shield. Healthy communities mean a better economy. https://www.bcbs.com/the-health-of-america/articles/healthy-communities-mean-better-economy. Published January 12, 2017. Accessed June 30 2020
[6] Engel G. The Need for a New Medical Model: A Challenge for Biomedicine. Science, 1977; 196(4286): 129–36.
[7] Stein REK, Jessop D. A Noncategorical Approach to Chronic Childhood Illness. Public Health Reports. 1982;97(4)/354–362
[8] Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006; 96(5):826–33
[9] Montroll EW. Social dynamics and the quantifying of social forces. Proceedings of the National Academy of Sciences. 1978; 75(10):4633–7.
