During my career as an orthopedic surgeon practicing in the Midwest, I have witnessed a variety of health inequities. But as a member of the human population, I am now aware of it as never before.
The Covid-19 Pandemic increased our awareness of health inequities. We saw increased rates of Covid and decreased rates of vaccination among groups that included racial and ethnic minorities, as well as individuals living in rural communities.
Healthcare providers have been aware of health inequities for years. For many of us, the enormity of the issue created a sense of helplessness. If we can convert the growing discussion into bold action, then solutions to address inequity can emerge.
I hope to propose solutions in future posts, but right now I will simply identify some of the challenging situations I encounter routinely. Most of these challenges center around “social determinants of health.” These are conditions in environments where people are born, live, learn, work, play, worship and age that affect their health. Social determinants of health may include access to education, housing,lihn transportation and healthcare.
Before I dive into it, here are a few terms I have been boning up on recently:
Health equity means everyone having a fair and just opportunity to be healthier.
Health disparities are differences in health outcomes.
Health inequity refers to differences in health outcomes that are avoidable, unfair or unjust.
The Issues I have Seen First Hand
This is an enormous challenge for both patients and care systems. Without insurance or “good paying” insurance, patients either do not come in for routine care or only access care in the expensive and inconvenient emergency room system. Specific to my field, if someone does not have insurance, they probably will not get a joint replacement, even if they need one. This inevitably leads to chronic pain and disability.
Access to care
Lack of access to care shows up differently for each patient. There are those who live in rural areas and must travel two hours to a hospital. Other urban residents may not have reliable access to transportation. For this second subset of patients, the likelihood that new facilities will be in suburbs exacerbates inequity.
The 15-minutes-late cancelation policy that many health systems adhere to is often a barrier for both rural and urban patients. While this policy promotes efficiency, it also results far too often in patients who live far away or lack transportation missing out on crucial care. Without safe, reliable and cost-effective transportation, these issues are exacerbated and create inconsistent delivery of healthcare.
Access to Technology
As society pursues modernization, technology advances every year. With advancement come more opportunities to access care outside of traditional healthcare settings through virtual visits and telehealth. However, without access to high-speed internet services and compatible devices, such as computers, tablets or smart phones, many patients are unable to access remote care.
Education is important to preventative care. People need to know when to have routine checkups, which symptoms indicate bigger health issues, and how to access proper and timely care. Even in the event of a major surgery, educational materials may not match a patient’s understanding, reading level, or English proficiency level.
Malnutrition results from a diet that does not supply a healthy amount of one or more nutrients. This includes diets that either lack nutrients or provide them in such abundance that the diet causes health problems. Problem diets may lack or overabound in calories, protein, carbohydrates, fat, vitamins, or minerals. Both timely intake and access to appropriate foods are essential for optimal outcomes. Many communities and groups lack access to healthy and affordable food.
Though related to nutrition, the seriousness of obesity merits specific mention. Obesity is a frequent cause of several co-morbidities that lead to health problems. In orthopedic surgery, it is common practice for surgeons not to perform joint replacement on patients with a BMI in excess of 40. While this measure is an effort to limit complications, it is very difficult for high pain patients to lose weight (and thus lower their BMI). Circling back to equity, most weight-loss programs are ‘cash pay.’ Many patients cannot afford the costs and will face pain and disability.
At minimum, housing must be safe, secure, and provide clean water. Although some patients who are homeless or have unstable housing receive healthcare, this scenario often increases the likelihood of fragmented care resulting in suboptimal outcomes.
Language barriers are an exceedingly frequent challenge in healthcare. In most cases, health systems seek solutions, but experienced interpreters of certain languages and dialects are hard to come by outside of major cities. Even when health systems can offer appropriate resources, patients and care teams still often experience confusion and miscommunication.
Support from Friends and Family
The work of an entire clinical care team is necessary for optimal patient outcomes. The same can be said about support from friends and family. People often underestimate the value of community around patients undergoing medical care. Whether it is a loved one’s consistent call to check in, a timely text reminder to take a medication, or an offer to bring over a meal after surgery, a patient’s support level significantly affects surgical outcome. Inconsistent support contributes to suboptimal outcomes.