Like many cities in the United States, Boston faces strong racial and socioeconomic disparities. This problem becomes more apparent when one looks closely at the health inequalities that exist between Boston neighborhoods. For example, residents of Back Bay have an exceptional life expectancy of 92 years. Compare that with a neighborhood like Roxbury, where residents can expect to live for only 59 years. That’s a difference of 33 years, just four miles away. Research shows that factors such as access to health care, affordable housing, and clean air can all make a difference in a community’s overall health and life expectancy. GBH All things Considered host Arun Rath discussed these disparities with Dr. Tom Sequist, the Mass General Brigham’s chief medical officer, who is researching ways to close the health gaps the city faces. This transcript has been lightly edited for clarity.
Arun Rat: To start, give us a bit more detail about the inequalities you have seen working with city dwellers and how people are affected by this on an individual level.
Dr. Tom Sequist: There is a long tradition of measuring and describing health inequalities in the country. He had a very big spark around 2001 with the Institute of Medicine’s “Unequal Treatment” report. Since then, this large volume of information has described these inequalities and they range from things like chronic disease outcomes to acute care and mental and behavioral health issues. I think the most urgent fire that has happened recently was in the spring of 2020, at the start of the COVID pandemic, when there really was an even more intense spotlight shining on the fact that we We were experiencing dramatic differences in health outcomes at that time. point, obviously related to the COVID-19 infection.
Rat : I know from working and reporting during the pandemic that it really felt like, once the pandemic hit, we had stories that really hit health care disparities pretty much every week. Talk about how the pandemic has affected things. I mean, it got more attention. Is there a way to reasonably compare how things are or how they have changed?
Sequiste: I think the most important thing that happened in that time, if we go back to the spring of 2020, is that we saw the impacts of social risk factors, structural racism on health care outcomes when it comes to COVID-19, but those factors were actually still there for decades and decades. They were probably happening over a longer period of time, like complications from diabetes or complications from heart disease, which can take years and years and sometimes decades to see the inequities. What happened in the spring of 2020 is that it all happened in fast forward, like almost like a fast moving train. Within weeks, you could see three to five times differences in mortality from COVID-19 between communities and between people of different racial and ethnic backgrounds. I think the speed and the trauma that everyone went through at that time really woke everyone up to how important these inequalities are. If you were trying to pull off a silver lining, it’s really spurred a whole new wave of activity that aims to address equity, anti-racism, and health care as public health crises. You’ve seen organizations like the CDC call it one of the biggest public health crises we have right now.
Rat : If this is a situation where we have these huge disparities over a distance of just a few miles, we’ve come to this because it’s a situation that has developed over decades and decades, like you say so. Obviously, we don’t want to take decades and decades to fix it. How can we even assume that?
Sequiste: Well, I think the really important thing that we need to consider first is actually what you quoted here. This has been going on for decades, if not centuries, in many of these communities. So it’s unlikely we’ll fix this in a year or two, even though we have a lot of pent up energy and people who really want to work in this space. We just need to set realistic expectations for how long it will take us to resolve these issues.
Then the next thing we have to do is say, “OK, well, why is this going to take us so long?” Because these are truly monumental challenges and issues that we face here. This means that to be successful in this area, we need true partnerships and collaboration between delivery systems, between public health organizations, between government organizations and, most importantly, between leaders and community organizations. We need these large-scale collaborations and coordination. There have been many examples of projects that bring together these various stakeholders, perhaps not exhaustively, but a few of these stakeholders at a time, and you can demonstrate in a pilot program in a way that you can address to inequalities.
However, what we really need and what our moment calls for now is to do these kinds of things at scale and to have an impact and to measure and demonstrate that the programs that we develop at scale with this type of collaboration really changes the lives of the people who live in these communities. That’s what I think would be a really remarkable result of the last few years.
Rat : Give us some examples of the kinds of things you would ideally like to be able to scale.
Sequiste: Well, I think what we should do is we should take an evidence-based lens and ask ourselves what are the main causes of inequity in health outcomes within our communities? If you look at this, it’s very clear that one of the things that keeps coming up is that the cause of health problems, morbidity and mortality in many diverse communities is heart disease. How do we approach heart disease globally? Part of it is the treatment of the health care system, like health care systems like mine. How do we manage high blood pressure or high cholesterol? How to manage patients who come to the emergency room with a stroke or a heart attack? It’s actually much bigger than that. We have to think about the fact that, say, 7-10% of people may suffer from cardiovascular disease in the form of a heart attack or stroke. However, double or triple those numbers may have high blood pressure or high cholesterol.
We need to do a better job of upstream management of food insecurity, job security, and housing security, because those things really predict the kinds of diets people have, the ability to have time to exercise and adopt other healthy lifestyles, all of which will contribute to better results. To remedy this, these are not necessarily interventions that can be carried out by a hospital system. We would like to involve public health organizations and government programs down to policy levels, but also community organizations that can develop programs like mobile van programs, that can bring care and screening and prevention programs to the doorstep people. We may want to partner with agencies that can provide transportation services so that patients can get to their clinic visits. They can have their blood pressure checked. But all of this requires really intense coordination.
I would go back to what I started, more evidence-based, we really want to focus on measuring everything we do and making sure we’re having that impact and reducing the burden of, say, heart attacks and strokes in this case.
Rat : Big deal and it’s really helpful that you break it down like this for us. Thank you so much.
Sequiste: Thank you so much.
