Avila on Achieving Equity in Health Care

At our 2020 annual meeting, “Achieving Equity: A VAHHS Virtual Meeting,” Dr. Maria Mercedes Avila kicked off what we hope will be a strong commitment from Vermont’s health care system to remove the health disparities that exist here in the second whitest state in the U.S.

Avila described the term disparities as conditions that are “unnecessary and avoidable, unfair and unjust.”

She also offered a definition of “health equity”—when everyone has a fair and just opportunity to be as healthy as possible.

She stressed that disparities are preventable if we do the hard work to ensure certain behaviors don’t take place and that we address and eliminate inequality. Yet, as she led health equity workshops across the US with almost 10,000 providers, she reports that 36.2 percent of them said they previously had little or no training in how to do so.

“We have to have ongoing training,” she offered. “And it has to happen within the workforce.

“Health disparities disproportionately affect groups historically disadvantaged in our society,” she noted. “Most providers [surveyed in workshops] didn’t understand the connection between racial disparities and health disparities. We need to understand the root cause of racial disparities and inequties in our society to understand why we have racial disparities in health today. We all need to know the history of where racial disparities came from,” she explained, adding that her trainings often begin with a history lesson.

She said a great majority of providers attribute disparities in health outcomes to patients’ behaviors instead of providers’ behaviors. Some even question the legitimacy of health disparities. This is all, she stated, part of systemic racism.

“There’s an urgent need to address disparity because it’s a moral wrong,” she noted.

COVID-19 has in many ways resurfaced disparities. Americans of color (and also Vermonters of color) have been disproportionately harmed by the pandemic in many ways.

“Black Vermonters are overrepresented among COVID-19 cases, making up 1.4 percent of the state pop, but 14 precent of confirmed positive cases,” she noted.

Some posit this stems from the fact that people of color have a higher rate of the “underlying conditions” that cause more people to fair more poorly after contracting the virus. Among these conditions are diabetes and hypertension.

“Racial disparities contribute to underlying conditions,” Avila said. “Underlying conditions are the direct result of exposure to poverty, redlining, gentrification, food deserts, health care disparities and, most importantly, environmental, structural, systemic and institutional racism. Whenever we provide data around underlying conditions, we need to keep in mind these historical impacts of systematic oppression in the United States and the systemic and structural conditions that are causing many groups not to be able to thrive in our society,” she related.

She worries that racial disparities related to COVID-19 could intensify as we continue to response to the crisis, even after we find a vaccine.

“The distrust that exists [among disadvantaged communities] with government and health care organizations—these are pieces we need to address to ensure that all communities have access to, for example, vaccines,” she said, pointing to eugenics and other horrific factors that have sewn distrust.

Avila polled attendees about what they thought the ratio was between the net worth of the average white family and the average Black family, then revealed the in 2014, the average white family had 17 times more wealth than the average Black family.

“In the latest data from 2018 and 2019, it appears to be closer to 20. This difference was only eight-fold in 2004,” she related, starkly demonstrating that we are not making progress.

“COVID will increase this difference,” she added. She noted that wealth disparity is the direct result of practices like “redlining” that occurred from the 1930s to the 1960s. Diverse communities couldn’t access loans during several decades because the government Home Owners’ Loan Corporation marked majority-Black districts in red on maps so banks wouldn’t extend government-insured loans in those areas. This had the effect of suppressing Black home ownership and business development.

Avila and others in her field are currently holding focus groups to look at the impact of COVID-19 on refugees and immigrant communities.

“We are learning from the communities that information dissemination [about COVID precautions] didn’t reach them in real time. There’s still a lot of confusion about COVID-19, about vaccines, treatment, anything to do with coronavirus,” she said. “When we have communities where there is limited English proficiency and members cannot speak in English, we have to make sure they have access to the same information in real time.

“Patients must be able to participate in their care.,” she noted, adding that her own mother in Vermont doesn’t speak English and that experiencing the health care system as the family member of such a patient has contributed to her dedication to ensuring all patients in Vermont and nationally have access to communication.

She gave health care leaders advice on the types of training that could improve equity in health care.

“We need to be focusing on critical thinking and emotional intelligence,” she said. “So many times, we focus on training and education on the intellectual level, but I always say in my presentations that we need to focus on opening people’s eyes, minds and hearts. We need to work with communities, not in them.”

She brought up the concept of “structural competence or humility,” where providers truly understand that patients’ health risks, symptoms and concerns are not related to personal choice, but are the direct result of their belonging to historically disadvantaged groups within social, political or economic systems (Metzl and Hansen, 2014).

“This is an ongoing developmental journey,” she stressed. “The more work we do to understand this, the more we realize that we didn’t know much to begin with.”

She introduced the National CLAS Standards, with which 73 percent of attendees were not familiar. CLAS (Cultural and Linguistically Appropriate Services), designed by the Department of Health and Human Services in 2011 modified in 2013, guide the way health care organizations should do the work to eliminate health disparities.

She laid out a number of ways we could begin our journey to achieve health equity:

• Addressing disparity through important programs that include State Department of Health guidelines and CLAS.
• Recruiting more providers to work with un-served and under-served populations.
• Instituting cultural knowledge and diversity in the workforce.
• Allocating resources for institutional needs around programs seeking to increase equity.
• Employing more community outreach workers hired from communities where we have disparities and creating advisory councils on which community members sit.
• Hiring, training, retaining and promoting bilingual/bicultural providers.
  Improving education and communication among diverse populations and providers.

While Avila acknowledged that our journey toward true health equity was long and would be complicated, she did give one simple piece of advice:

“When in doubt, ask the patient,” she said. “The ‘best practice’ is ultimately what is best for those we serve. Work with them in partnership and collaborate with them.”

Dr. Avila is available for workforce consultation and training and can be reached by email at mavila@culturalrs.com.