Let’s Do Our Part to Narrow the Gap...
Hippocrates walked the Earth in 400 BC. You know what is amazing? We are still quoting his words. Some have suggested his musings are antiquated, but if one takes a deep dive into his oath, his teachings remain profound, some even speak to a universal health care system, treating “man or woman” and “pauper or prince” with equal respect.
Sadly, inequalities have been around for more than 8,000 years. Grave sites from the Neolithic Period identified overrepresentation of men in cave art with biased burial patterns. Men, who accounted for the majority of formal burial sites, were laid to rest with tools, arrowheads, and precious metals, while the small number of women were buried with ceramics. Gender and racial inequality is not determined by biologic differences, instead it is cultural. Whether we want to admit it or not, health inequities and health disparities are the consequence of gender and racial inequality, though often more subtle.
Elimination of gender and racial inequality is the right thing to do. So, in medicine, what is holding us back?
The last few months around the globe have been filled with divisiveness and conflict but the medical profession is held to a higher standard, as it should, in regards to interpersonal communication skills, systems-based practice, and professionalism. Cultural variability leads to differences in the definition of professionalism. The Western world focuses on patient rights, East Asia on respect and responsibility, and the Middle East on morality and personal character; regardless, they all funnel down to the need for compassion and integrity when dealing with patients, patients’ families, and colleagues both in and out of the operating room. The overarching theme, as Hippocrates first implied, includes a commitment to society as a whole.
Health disparities are differences in outcomes. Health inequities are differences in opportunities, expo-sure, and resources. Inequities have to do with all that comes before the outcomes are realized. The Department of Health and Human Services “Healthy People 2030” notes that socioeconomic outcome gaps for cardiovascular measures such as ESRD in diabetes and timing of intervention for acute MI have dramatically narrowed since 2000, but important disparities remain. Inferior outcomes following CABG in both women and underrepresented minorities persist, and underrepresented minorities more often undergo CABG by low-volume surgeons in hospitals with higher risk-adjusted mortality rates. Such disparities result from unequal access to and receipt of quality health care. Studies demonstrate that providing equal access can eliminate racial differences in lung cancer survival. The same is likely true for the majority of other disease processes we treat. Health disparities will only be eliminated when health equity is achieved.
We tend to focus on the negative in healthcare delivery, but progress has been made. Dr. Nick Kouchou-kos in his 1999 STS Presidential Address noted the paradox that while the US is the wealthiest nation and spends the most per capita on health care, 16% of the population lacked health insurance, including 12% White, 22% Black, and 35% Hispanic. More recent data from 2019 reports only 8% without insurance, including 5% White, 10% Black, and 17% Hispanic. Most importantly, the gap has narrowed for children. Uninsured children fell from 15.4% in 1999 to 5.2% in 2019, including currently 4.3% White, 4.6% Black, and 8.2% Hispanic. While there is general improvement, these data demonstrate that gaps still remain. Preventive measures and early detection, accomplished by allocating resources according to greatest need, may impact outcomes by decreasing the disease burden in the hardest hit populations.
The UNICEF “Narrowing the Gaps” project demonstrates the superior benefit realized from an equi-ty-enhancing approach to interventions. Return on investment directly correlates with the needs of the population. The number of lives saved by investing in health and nutrition interventions for the poorest children yield nearly twice the number of lives saved than would be saved with an equivalent investment in less deprived groups. The Cardiac Surgery Intersociety Alliance (CSIA) is the first ever transcontinen-tal collaboration of all the major cardiothoracic surgical societies. The AATS partnered with ASCVTS, EACTS, and STS with the goal to improve access to millions of children suffering from rheumatic heart disease. The CSIA may be the perfect vessel through which to focus global cardiothoracic surgery efforts with an equity-enhancing approach.
Let’s pledge to lead the way in cardiothoracic surgery as Hippocrates outlined 2,400 years ago with beneficence, integrity, respect for patients, mentors, and mentees, and personal and professional virtue in our quest for social justice.
Marc R. Moon, MD
AATS 101st President