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Ignoring Goldfarb’s Warning: Why Studying and Addressing the Social Context Matters

2019; Elsevier BV; Volume: 219; Linguagem: Inglês

10.1016/j.jpeds.2019.11.014

1097-6833

Nia Heard‐Garris, Karen Sheehan, Elizabeth R. Alpern,

Community Health and Development

See related article, p 209Dr Stanley Goldfarb, former University of Pennsylvania School of Medicine Associate Dean of Curriculum, wrote an incendiary Op-Ed for the Wall Street Journal in September 2019 arguing that medical schools should not be hubs of social justice and social policy change.1Goldfarb S. Opinion | Take Two Aspirin and Call Me by My Pronouns. Wall Street Journal.https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291Date: 2019Date accessed: October 14, 2019Google Scholar He warned of a "new wave" of medical educators who highlight health disparities and promote diversity and inclusion at the expense of mastering the science of medical training. However, Goldfarb's arguments ignored decades of empirical research that demonstrate the contribution of the social context to population health and subsequent health disparities. In this volume of The Journal, a study by Rees et al adds to this growing body of evidence.2Rees C.A. Monuteaux M.C. Raphael J.L. Michelson K.A. Disparities in pediatric mortality by neighborhood income in United States emergency departments.J Pediatr. 2020; 219: 209-215Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar This study illustrates the intersection of social context and pediatric-focused population health, namely, which children are more likely to die in the emergency department (ED).2Rees C.A. Monuteaux M.C. Raphael J.L. Michelson K.A. Disparities in pediatric mortality by neighborhood income in United States emergency departments.J Pediatr. 2020; 219: 209-215Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar See related article, p 209 Rees et al examine the association between median neighborhood income and ED pediatric mortality. The authors found an inverse relationship between neighborhood income and pediatric mortality, that is, as median neighborhood income decreased, pediatric mortality increased. In addition, they found that uninsured and publicly insured children had a greater incidence of ED mortality as compared with privately insured children. Interestingly, there was no interaction between median neighborhood income and insurance status, which means these factors were independently associated with ED mortality. This rigorous study boasts many strengths, including the use of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample, a nationally representative data set that included more than 64 000 pediatric ED deaths, and pairs these data with median neighborhood income based on the zip code tabulation area quartiles taken from the American Community Survey of the US Census data. Although this study used nationally representative data to highlight important and unacceptable disparities of "place" and insurance related to pediatric mortality, the study's limitations offer avenues for researchers to continue advancing this field. For example, zip codes are a crude measure of neighborhoods, such that zip codes may encompass multiple neighborhoods and the median income for a zip code may not be aligned with a patient's income, the patient's actual neighborhood income, or reflective of a singular neighborhood's resources. This mismatch could have potentially led to a misclassification bias, either under- or over-representing the association of neighborhood income and mortality for particular groups of children. However, neighborhood-level data were not easily accessible for this study, highlighting the data limitations faced by researchers who are interested in studying social context and health. Future data collection and subsequent studies should consider asking participants to identify the closest cross streets or self-identify neighborhoods3Coulton C.J. Korbin J. Chan T. Su M. Mapping Residents' perceptions of neighborhood boundaries: a methodological note.Am J Community Psychol. 2001; 29: 371-383Crossref PubMed Scopus (369) Google Scholar and use this information to more accurately capture relationships at the local neighborhood-level. Although this study did use neighborhood-level income data, it missed an important opportunity for deeper analysis by failing to examine race/ethnicity. Race and ethnicity composition are readily accessible in the US Census tract data and could have been added to the existing analysis.4ACS Demographic and Housing EstimatesACS—Year Estimates Data Profiles.https://data.census.gov/cedsci/table?d=ACS%205-Year%20Estimates%20Data%20Profiles&table=DP05&tid=ACSDP5Y2017.DP05&lastDisplayedRow=19Date: 2017Date accessed: October 14, 2019Google Scholar We need to distinguish whether it is truly a neighborhood's resources, which may be limited by economic opportunity and property taxes, as the main driver of the disparity in pediatric ED mortality or perhaps a proxy for structural racism experienced by racial/ethnic minorities. Although race/ethnicity and neighborhood location (ie, residential segregation) are linked and may be difficult to disentangle,5Massey D.S. Denton N.A. American Apartheid: segregation and the making of the underclass. Harvard University Press, Cambridge (MA)1993Google Scholar,6Williams D.R. Collins C. Racial residential segregation: a fundamental cause of racial disparities in health.Public Health Rep. 2001; 116: 404-416Crossref PubMed Scopus (1889) Google Scholar it is an important relationship to explore in the pediatric population. In essence, the next study could determine whether race and "place" interact to explain these pediatric mortality disparities. Scholars have argued that place, instead of race, is in fact the driver of racial disparities seen in adult health outcomes.7LaVeist T. Pollack K. Thorpe R. Fesahazion R. Gaskin D. Place, not race: disparities dissipate in southwest Baltimore when blacks and whites live under similar conditions.Health Aff (Millwood). 2011; 30: 1880-1887Crossref PubMed Scopus (229) Google Scholar Although this study brings us closer to understanding these factors, it does not answer whether it is place, race, or both that determine pediatric ED mortality. Furthermore, the interplay between the racial, historical, cultural, and individual factors that are associated with disparities in mortality need to be identified. Traditionally, scholarship that has focused on "place" has inconsistently integrated these social interactions with the physical environment to further explain these disparities,8Corburn J. Urban place and health equity: critical issues and practices.Int J Environ Res Public Health. 2017; 14: 1Crossref Scopus (54) Google Scholar and this study serves as a jumping-off point for work in the field related to pediatric mortality. Despite the limitations of the study, the authors reinforce that "place" matters for health and may help to explain the differences in mortality and, further, they use national data to illustrate this point. Irrespective of the specificity of the outcome—pediatric mortality within EDs, extant literature has supported the importance of "place" in relation to health and well-being. Within major metropolitan cities with high levels of residential segregation, these relationships are clear. In Chicago, for example, differences in life expectancy can be characterized with respect to a person's "L" (public transit train) neighborhood stop.9Schencker L. Chicago's lifespan gap: Streeterville residents live to 90. Englewood residents die at 60. Study finds it's the largest divide in the U.S. chicagotribune.com.https://www.chicagotribune.com/business/ct-biz-chicago-has-largest-life-expectancy-gap-between-neighborhoods-20190605-story.htmlDate accessed: October 14, 2019Google Scholar These disparities in life expectancy are unacceptable, widespread, and yet persistent. If Rees et al heeded Dr Goldfarb's warning and discounted the contribution of social context to health, this study would not have been done, thus limiting our understanding of disparities in pediatric mortality. An expert panel of educators, researchers, students, and community advocates recently affirmed that it is crucial to increase curricular time to teach students about the social determinants of health.10Mangold K.A. Bartell T.R. Doobay-Persaud A.A. Adler M.D. Sheehan K.M. Expert consensus on inclusion of the social determinants of health in undergraduate medical education curricula.Acad Med. 2019; 94: 1355-1360Crossref PubMed Scopus (31) Google Scholar,11Doobay-Persaud A. Adler M.D. Bartell T.R. Sheneman N.E. Martinez M.D. Mangold K.A. et al.Teaching the social determinants of health in undergraduate medical education: a scoping review.J Gen Intern Med. 2019; 34: 720-730Crossref PubMed Scopus (64) Google Scholar As the preventable deaths of children and adolescents rise,12Lee L.K. Mannix R. Increasing fatality rates from preventable deaths in teenagers and young adults.JAMA. 2018; 320: 543-544Crossref PubMed Scopus (19) Google Scholar it is not a leap to question whether the traditional biomedical model is sufficient to improve health. Even with increasing interest in the education of medical students on the social determinants of health,11Doobay-Persaud A. Adler M.D. Bartell T.R. Sheneman N.E. Martinez M.D. Mangold K.A. et al.Teaching the social determinants of health in undergraduate medical education: a scoping review.J Gen Intern Med. 2019; 34: 720-730Crossref PubMed Scopus (64) Google Scholar given the extent of health disparities, it will take more than medical student education to address and correct these disparities. Health systems need to be re-educated and positioned to help close these gaps. Fundamentally, this argument calls into question the duty or role of health systems that are anchored within communities. In addition to tracking and addressing disparities within individual healthcare institutions, health systems should consider their role in investing in communities, to eliminate these disparities.13Goodman P.S. When a Steady Paycheck Is Good Medicine. The New York Times.https://www.nytimes.com/2019/10/10/business/healthcare-anchor-network.htmlDate: 2019Date accessed: October 25, 2019Google Scholar,14Norris T. Howard T. Can Hospitals Heal America's Communities?.https://democracycollaborative.org/content/can-hospitals-heal-americas-communities-0Date accessed: October 25, 2019Google Scholar For example, health systems could address the housing, community investment, and transportation needs of their patients from the lowest resourced neighborhood.14Norris T. Howard T. Can Hospitals Heal America's Communities?.https://democracycollaborative.org/content/can-hospitals-heal-americas-communities-0Date accessed: October 25, 2019Google Scholar The Table (available at www.jpeds.com) presents a nonexhaustive list of health system approaches to advance health equity. Ultimately, between 60% and 80% of a population's health is influenced by nongenetic factors that are outside the clinical setting.14Norris T. Howard T. Can Hospitals Heal America's Communities?.https://democracycollaborative.org/content/can-hospitals-heal-americas-communities-0Date accessed: October 25, 2019Google Scholar,15Schroeder S.A. We can do better—improving the health of the American people.N Engl J Med. 2007; 357: 1221-1228Crossref PubMed Scopus (721) Google Scholar Both medical students and health systems should know this and act on it to improve the health of children nationwide. Future generations of clinicians and health systems must acknowledge that an individual's social context influences health across the lifespan and may be key to eliminating health disparities. Clinicians, scientists, and health systems alike need to disregard Goldfarb's warning to advance both the science and practice of medicine. The work of Rees et al helps us to understand the dire consequences of ignoring these issues. TableHealth system approaches to addressing health equity within communitiesDomainsPracticesHousing•Building temporary or sustainable housing•Renting hospital-owned, low-income dwelling unitsCommunity investment•Providing loans to community members•Committing to use local vendors or small business when availableWorkforce development•Hiring practices that target low-resourced communities•Supporting employees from low-resourced neighborhoods (onsite, affordable childcare; transportation assistance; offering a livable wage; employee assistance programs; ongoing job training/career development programs)Transportation•Working to establish optimal parking and public transit availability and costs•Establishing free/low-cost shuttle options Open table in a new tab Disparities in Pediatric Mortality by Neighborhood Income in United States Emergency DepartmentsThe Journal of PediatricsVol. 219PreviewTo evaluate emergency department (ED) pediatric mortality by patient neighborhood income. 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