Overcoming Public Health / Clinic / Community Bias (12:31)

In Joneigh Khaldun’s work as an emergency physician at Henry Ford Hospital and Director and Health Officer for the Detroit Health Department, she has unique insight into two different worlds.

One of Khaldun’s health department responsibilities is to review death circumstances to try to develop strategies that prevent further unnecessary deaths. She describes one of her cases, a young toddler born pre-term to a single mother who had struggled with domestic violence.

The toddler, whom Khaldun calls Destiny, had visited the emergency room a couple times for minor complaints like a cold. She’d also visited the health department seeking several services. Both of her parents had struggled with addiction and been in and out of jail, and an older sibling had truancy issues and had also been in and out of the emergency department for minor injuries.

One day, Destiny’s mother went to work, leaving her toddler with a friend. Two hours later, the child was dead.

“What happened to Destiny was a failure of many things, including the health care system — a system that is fragmented, does not sufficiently integrate with the public health and social service world,” says Khaldun. “It’s a place where every day there are missed opportunities to improve health, connect individuals to the appropriate services, and to prevent unnecessary deaths.”

It’s well known that only 10% of someone’s health is determined by what happens inside a hospital or doctor’s office. What really determines a person’s health are their living circumstances, such as housing, education, jobs, access to healthy foods, and safe places in which to live, work, and play.

The U.S. spends over $3 trillion on health care each year, the equivalent to over $10,000 per person. Despite that, when compared to other wealthy countries, it has the lowest life expectancy rate, and significant disparities in health outcomes. Where you live and how much money you make significantly impacts how healthy you can be.

“Until we figure out a way to work more upstream on health problems, we will continue to pour trillions of dollars into a health care system that is not sufficiently improving health,” Khaldun says. “It’s like pouring sand into a bucket with a large, gaping hole and wondering why the bucket never fills up. We will only be able to change health systems and health outcomes by plugging that hole, and we can do that by creating strategically integrated partnerships between public health, health systems, and the communities that they serve.”

To succeed, these partnerships must do three things well:

  1. Recognize each other’s value.
  2. Be genuinely inclusive of the community.
  3. Define and be held accountable for real outcomes.

Recognize Each Other’s Value

Start by recognizing and eliminating biases and work to understand the critical role that each partner plays in improving health.

Khaldun describes various biases she’s encountered. On the public health side, some might think that doctors only care about getting paid or publishing the next big academic paper. On the health system side, physicians might think health departments are only good for sending over social workers or giving out vaccines. “And some folks believe that people in public health are a little too fluffy, [that] we spend too much of our time on those health education programs,” she says.

These biases come from working in separate sectors. Medical training doesn’t focus much on public health, and while community-based participatory research is expanding, many people still struggle with it.

“For a successful partnership, we have to recognize and address these conscious and unconscious biases and come together respectfully, recognizing the value each sector has to play in improving health outcomes,” says Khaldun.

Most doctors went into medicine because they genuinely want to help people. While a doctor or hospital’s reach may be limited, there are still things they can do to broadly improve the health of their patient population, Khaldun explains. From her emergency physician viewpoint, this could be anything from setting up an ED vaccination program during an infectious disease outbreak; to connecting victims or perpetrators of youth violence to services, jobs, and housing; to reviving someone from an opioid overdose and immediately connecting them to addiction services instead of “treating and streeting.”

Well-run health departments can leverage and scale resources to broadly impact the health of a population, such as expanding access to contraception, STD prevention services, and preventative screenings. Health departments have access to data and technology that address an entire population, and they can help develop and implement broad policies on things like improving air quality, making sure businesses sell safe food, or helping to prevent lead exposure to children.

“Once health systems and local public health departments can understand each other’s value, this can be the foundation upon which other partners are welcomed in, whether it’s universities, businesses, nonprofits, or the faith-based community,” says Khaldun.

Be Genuinely Inclusive of the Community

“Sometimes, whether in public health or the health care system, we don’t stop when we are creating our grant or our program to ask the community what they really think the challenges are — and we certainly don’t ask the community what they think the solutions are to those challenges,” says Khaldun.

“There’s an unconscious perception that those who do not have doctoral degrees, publications, or titles cannot be involved in a project from the beginning to the end,” she adds. “Best case scenario, we invite them to a forum to respond to our plan, and we wonder why our interventions fail or why the community rejects us when we come to them with our perfectly laid-out plan.”

But one does not need a degree to understand the conditions in which they live, their needs, the assets of their community, and how to leverage those assets to build community health. “Community members must be respected for the perspectives that they bring, the solutions that they hold, and not seen as helpless victims who need to be told what is good for them or have programs done to them,” Khaldun says.

Define and Be Accountable for Real Outcomes

Partnerships must establish clear, community-focused objectives and outcomes and be held accountable to the community, CEOs, government officials, and funders. “We have to collectively force ourselves to be focused on real outcomes that are reflections of whether or not our work is improving health, and we have to honestly look ourselves in the mirror if the outcomes aren’t changing,” says Khaldun.

“What if the true outcome we were all held accountable to was whether or not the community’s health was better? What if reimbursement to hospitals and doctors was withheld if the broader community’s health did not improve, regardless if a small, private project or research study had positive results, or a clinic saw its targeted number of patients who had the recommended hemoglobin A1C? What if funders no longer funded siloed programs that did not show real impact?” Khaldun asks.

“There is no winning in community health if the community’s health does not improve, and that means having some honest conversations about true outcomes and metrics, tracking progress, and making tough decisions about how we continue to strive and grow together to improve health.”

“There is a lot of great work going on and we’ve made a lot of progress,” Khaldun says. “But until we are able to break down those barriers and biases that inhibit true inclusivity, and hold ourselves accountable to real outcomes, we will never reach our true potential: an imperative to improve community health, which is why we all went into health care in the first place.”

From the NEJM Catalyst event Essentials of High-Performing Organizations, held at the University of Michigan’s Institute for Healthcare Policy and Innovation, July 25, 2018.

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