Abstract
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Now, it may shock you to know that by our health statistics per capita in Washington, DC, we are number one in not good ways. We are number one in cancer mortality, end-stage kidney disease, and HIV. As with averages, there is actually more variability within counties than across counties. When you look at Ward 8, the HIV rate there is the same as Namibia's. The infant mortality rate is the same as El Salvador and Cambodia.
So why is that? Well, there are differences in income. I live in Ward 3. The average family income where I live is about $220,000 a year. In Ward 8, it is $22,600, which is more or less what I pay in taxes.
So, let me tell you a little bit about Barry Farm, which is the poorest of the poor within Ward 8. That whole area was going to be one of the port cities, and then Alexandria took over, and it did not end up being a port city. Barry Farm was the Barry Farm tobacco plantation. After the Emancipation Proclamation, 400 acres were given to the freedmen, and they transformed it into a thriving African American farming community.
They built Howard University. And just to show you how things have changed, they would work all day and then take their lanterns, walk from all the way across there to Howard University, and they built that university. At the heyday, one in four residents of Ward 8 attended Howard. Now one in four is in the prison system.
And what is happening now is that this is prime real estate. The venue, everything is quite beautiful. But there are many challenges, and I want to mention housing, and link to the social determinants of health.
If you have got a block where there are 10 houses, and 2 of the houses are appraised for 50,000, and the others are appraised for 30,000, they take the average of those property values, and that is how they come up with affordable housing numbers. So, the eight families in those $30,000 houses are going to be automatically unable to purchase them.
There is the challenge of returning citizens in Wards 7 and 8. Some good news, though, is some of the middle-aged men are beginning to return, and according to residents of Ward 8, where I did a listing tour, this is seen as something positive, which will impact not only on the boy children but also on the girl children. Girls have been, sadly, acting out a lot, and part of that is because of missing fathers.
There are no pharmacies that are open 24/7 in Ward 8. There are pharmacies that are open usually during the week, not after hours. One thing you should know about Washington, DC, we have probably the best access to primary care in the country because we have Medicaid. Back when we were dealing with the AIDS epidemic, having an AIDS-defining diagnosis automatically qualified you for Medicaid. So, if it was just a matter of access to healthcare, we would be number one in terms of positive outcomes. We are not. This is not unique to DC. The specifics may be a little bit different, but this is happening all over the country.
What are the social determinants of health? Social workers invented the social determinants of health. Nurses certainly, and other healthcare workers, get this. But, physicians do not get it. And sadly, because of the hierarchy of our system, if physicians do not get it, that has a negative effect on the rest of the system.
Basically, especially as physicians or clinicians, we think that we have such a big impact on outcomes, and of course we do for seriously ill people. But overall, our contributions are not a whole lot.
In Barry Farm, the amount of construction that is there, the amount of poor-quality air, and water are an issue. Individual behavior matters, but individual behavior is related to access to foods and sidewalks and housing. Genetics is not just an on/off switch. There is the microbiome. There are epiphenomena that are related to exercise. Stress probably is going to figure into this. Healthcare is just between 10% and 20% of the factors.
One of the strongest social determinants of health is high school graduation. The graduation rate in Ward 8 is only 42%. That really sets the trajectory for the rest of their lives. Impacting that number, just moving it a little bit, will have a big impact that will impact generations to come.
The more educated you are, the more likely you are going to breastfeed, because you recognize the importance. That may be a factor. You also have the resources that will allow you to prioritize breastfeeding. Either you can take time off from work, and you are maybe living in a two-income family, or you are in a workspace where there are rooms for nursing mothers.
I want to share my personal story, because I think as we reflect about our own individual careers and our work, it is important to know first why we went into the fields that we did.
I went into medicine—I was one of these people who was not 5 years of age when I knew that medicine was—I actually was 19. I was in college. Because I liked everything. Everything was interesting to me. I did not come from a physician family, but I came from an academic family. My mother is a medical anthropologist, so she is always telling me that, “Do not think you are so great because you are a physician. Anthropologists knew this long before you did and described it.”
I decided to go into medicine not just because of my love of science and service, but really for reasons of social justice. I come from a family wherein social justice is multigenerational. That is what drives me.
If that is what drives us—and I believe that that is something that we all share, given the topic—we must be more deliberate about thinking about that and weaving it in, because, what happens is that all of us, we get so caught up on a day-to-day basis in what we are doing that it is important to step back.
I established the Rodham Institute in Dorothy Rodham's honor. The reason I decided to honor her was that her personal story was one of being able to transcend a difficult childhood. She was dropped off and shipped out from Chicago to a place near San Diego to grandparents who were not very nice, actually borderline abusive, and they kicked her out of the house at age 14. Strangers took her in and said, “Look, if you basically clean the house and watch the children, we will let you finish high school.” Education for her was a priority. And let me tell you, even at 92 and a half years of age, she was one of the most intelligent people I have ever, ever met. Voracious reader with a dry wit.
The principle of the Rodham Institute, which is dedicated to health equity, is really working with communities and doing it in a way that is respectful, that is transparent, and that is bidirectional. Academic medicine not just has a history or a legacy, but really an ongoing legacy, of things being tilted against, especially, poor people and people who are either differently abled, of color, LGBTQ, older, and women. It is really important for us at the Rodham Institute, if we are going to go and do work, we are upfront about that.
I always say that gestures reflect principles. When we are meeting and trying to get to know different groups and organizations, we do not have people come to the mecca. We go to where they are. That makes a difference. And we listen. You know, I have the gift of gab, but when I am meeting new people, I try to listen.
Now, not-for-profit hospitals are required to do a community needs assessment. It is an IRS requirement. It was one of those perfunctory things, but now many institutions are really taking this more seriously.
This is an opportunity to impact policy within our institutions. If it is breastfeeding that the community decides that they want to look at, then that is something that you can design a program that will help to support that, measure it, and keep it going.
We have three areas of focus, our community collaborations, our HELP program, and our clinician service learning. In broad strokes, we as clinicians must be much more accountable to the society, not just to the individuals or to the families that we are serving, but really to the society. And we are increasingly being held accountable in a good way, I believe, at least under the Affordable Care Act linking our outcomes and reimbursement. I think that that is important. And that is what the public is demanding.
Have you ever seen a flock of geese fly to the south for the winter? It is never the same goose that is leading. They change up. I love pyramids, but this is one place where pyramids really do not have a role. We are the center. It is more like spokes on a wheel. The patient, the family, the society, communities on the center, but we are working together. And that represents a shift for how, certainly, physicians have been trained, and that is really an important thing. It is not just lip service. This is important for people to get, because it impacts not just our patients.
We have something called “See the City That You Serve.” We take all incoming interns, physician's assistants, students, nurse practitioners, occupational therapy students, and we start off at Foggy Bottom. We take buses, and we point out the monuments and so forth.
But then we cross over into Anacostia, because a picture is worth a thousand words. When they do not see any sidewalks, when all they see are corner stores with fried chicken and Chinese food, or no pharmacies, that is much, much more impactful than me talking for the next year. And on the buses, we have facilitators, our academic, and our community partners together, because we have an education council that is formed of both.
The Health Education Leadership Program targets middle and high school students from Title I schools. And this is meant to expose kids to health careers with a capital H—from public health to radiology techs to physicians, nurses. And even if they are not interested in going into a health field after this exposure, they can be health champions.
An unexpected thing that we found out when we are doing this is that our biggest success has been with black boys. And I use the word “boys” deliberately because we tend to overestimate black boys' age by 4 years on average. It is important that we remember that they are still boys and children, so I am deliberate. They are not little men, they are boys, they are kids.
And this is not for top-of-the-tier, gifted, talented students. These are more second- and third-tier students. Actually, we just found out 2 days ago that one of our kids who was teetering on not graduating from high school is going to walk in graduation, which I think is a big deal. The program is not only academics, but includes leadership, community service, and professionalism. So now what we are seeing is that these same kids are coming back and being big brothers and big sisters.
I alluded to the fact that staff and physicians, it is a very two-tier system. So, we offer this program to many people, but we decided to start with the children of the staff who work at George Washington, because, guess what, many of them are from Wards 7 and 8.
If I as a physician wanted to go to conferences from sunup to sundown, I could go all day. But, yet, for the people who work right alongside with us, well, maybe there might be an in-service here or there, or they may be told what they need to do better, but there is really nothing.
And yet, first of all, we are a team interacting with patients. And second, they are from the areas that are impacted by these social determinants of health. So, we have been doing lunch-and-learns, not just for the social determinants of health, but also for their health, for careers. They can figure out how to advance their own education, which studies show that that has a halo effect on the rest of the family.
We created a citywide consortium, Pathways—PATH-C, Pathways for All to Health Careers. We have the Black Nurses Association, all the academic institutions working to create some of these opportunities together. And it is modeled after the Alameda County health program. Please go to our website to learn more details.
I met Tyler when I was at an event. He is 6 years old. He was sitting with a bow tie and his glasses. He was not wearing a suit. And I said, “Oh,” I said, “What is your name?” He said his name. I said, “I bet you like math, do you not?”
He goes, “I do, and I like reading, and I am reading a book right now on Dr. Drew, Charles Drew.” I said, “Oh.” He said, “Did you know that Dr. Charles Drew invented the blood storage system?” I said, “Yes, I did.” “Did you know that he is from Washington, D.C.?” I said, “Yes, I did.”
“Did you know that when he was in a car accident and was bleeding, bleeding, bleeding, he went to a white hospital, and they refused to take care of him, and he died before he could get to the black hospital?” I said, “Yes, I did.” Six, 6 years old. So, I arranged a day for him to come and meet some other physicians. So, we have had some successes.
Our community collaborations. This has been just a wonderful thing, because I would say the first couple, 3 years we have been spending on just getting to know people, hearing, listening to what people want. And now that there is trust, people just think, “Hey, you know what? We would like to create a mental health clinic on site in our church. Will you help us do that?” Sure, because we are a people service. We are not coming in to impose.
Despite what sometimes gets presented about poor communities, particularly poor communities of color, I want to tell you that there is a lot of hard work and wonderful leadership and wonderful work to kind of help identify these problems from the people living in these communities.
We actually did an environmental scan that we commissioned a community health worker to do. It turns out that it is not HIV or diabetes or obesity or cancer that is the number-one health priority in Wards 7 and 8, it is mental health.
I want to close by discussing the Developing Families Center. There is this woman, I believe her name is Ruth. I have not met her yet, but I hope to. She is now in her early 80s. Fifty years ago, she decided that women in Ward 5, one of the other poorer wards in the city, deserved a place where they could have babies in a birthing center. It took years to realize that vision.
So, she worked and worked. She actually worked with Secretary Clinton, it turns out. She is working with one of the MacArthur Foundation recipients, who is now in her early 90s, who is helping run the center. She had Hechinger's, which was an old home goods store here that went out of business, donate the space.
We visited the site not too long ago. You walk in, it is beautiful. The rooms are gorgeous. Entire families stay in the rooms. There are quilts. Everything is handmade and just very cozy. There are places for the family. The mom usually has the baby in 4 hours and goes home.
And of course, it is mostly nurse practitioners and midwives who are around. They have got physician backup, but it is a nonphysician-run kind of place. And then child care begins at 8 weeks.
And we met a woman who herself had been a mother and came and had her baby there who is now working there. Can I tell you that outcomes are outstanding? Seventy-five percent reduction in C-sections. Seventy-five percent reduction in preterm labor and premies being born.
We can and should do better, and when we are looking especially at poor women, they deserve state-of-the-art, beautiful, clean places that are light and airy like the Developing Families Center. They have a garden that they are beginning to develop and grow. You go and you see the children. They are happy. They have a Head Start program there.
If we are going to make an impact on babies and mothers and fathers, I think that, of course, we have our individual lives and the space that we are working in professionally. But, we can look around in the informal ways that we exist to encourage a young woman to go to school or to ask these questions. It does make a difference. Or, invite a Tyler to come and join you for half a day.
Disclosure Statement
No competing financial interests exist.