Next Year In Cuba
Why Change Is Needed In Both Politics And Medicine
“Next year in Cuba.” My maternal grandparents, aunts, uncles, and mother immigrated to the United States during the 1960’s. I grew up hearing this toast at every Christmas and New Year’s celebration. The hope in the annual toast was palpable. The hope was that the system would change, that communism would fall, and they would finally be able to go home. Yet, change has been slow, both in politics and in medicine.
Healthcare disparities are prevalent in medicine. And efforts to reduce these disparities have been a focus of the national agenda for decades. Every ten years, the Department of Health and Human Services releases the Healthy People goals. These are evidence-based goals targeted at improving the health of all people in the US. One of the goals for Health People 2020 is to achieve health equity. The goal in 2000, was to reduce disparities, and in 2010 was to eliminate health disparities. Yet, disparities exist despite these goals.
The disparities we continue to face are not trivial. For example, childbirth is the most common reason for admission to a hospital in the US. Black women are four times more likely to die during birth than white women. Minority women are also more likely to experience severe complications, such as hemorrhage, postpartum infection, and severe lacerations during childbirth than non-minority white women. What is of concern is that the rates for both maternal morbidity and mortality are increasing, and births to minorities now exceed births to non-minority white women, therefore thousands of minority women are experiencing harm, during what should be the happiest moment of their life.
In order to eliminate disparities, it is important to understand what causes them. Disparities are complex, and there are multiple contributing factors, stemming from the patient, their providers, and even the healthcare system itself. Our group has done research to understand disparities in pain management during labor, and we found that oftentimes patients have fears and misunderstandings about their pain relief options, and these fears affect their decision-making. Providers may also be contributing to disparities. Providers may have bias, specifically, implicit bias, which affects their treatment recommendations to minority patients. And finally, the system itself, where minority patients seek care, could be affecting their outcomes. Elizabeth Howell recently found that minorities were more likely to deliver at minority-serving hospitals, which had higher rates of severe maternal morbidity.
One organization has proposed a framework which could be used to catalyze the necessary change. The Council on Patient Safety in Women’s Health Care is comprised of organizations that work together to improve healthcare for all women. The Council has created several safety bundles that contain evidence-based recommendations intended to improve patient outcomes. The Council recently released a bundle focused on reducing peripartum racial disparities, with elements that address patient-, provider-, and systems-level contributors to disparities.
To be sure, disparities will not be eliminated overnight. Changing systems are difficult, and only though the work of many, will progress begin to happen. Yet without awareness of disparities, and thoughtful efforts to reduce them, disparities will likely only continue to worsen in the US.
For many like me, my grandparents did not survive to see the death of Fidel Castro. Miami celebrated this past weekend. While change will not happen overnight, I have regained optimism, that next year, there will be change in Cuba, and more importantly, that there will be progress towards eliminating racial/ethnic disparities in healthcare.