>> When our communities need help, Blue Cross and Blue Shield companies step up with partnerships capable of preparing meals for thousands of families in need, because it's not just about health insurance.

We believe it's our responsibility to expand care to rural communities, protect our heroes with safety equipment, support local nonprofits.

These are our stories to help build stronger communities for the health of America.

>> "Second Opinion with Joan Lunden" is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.

>> All across America, there are complex and persistent racial differences in health and accessing healthcare.

People of color get sick at younger ages and die sooner than whites.

Compared with whites, members of racial and ethnic minorities are less likely to receive preventive health services and often receive lower-quality care.

On today's program, we will examine the racial disparities that exist in health and healthcare in America.

Joining our discussion is Mr. Wade Norwood, chief executive officer of Common Ground Health... >> Racial disparities are real.

And they have to be confronted.

>> ...Dr. Nancy Bennett, professor of medicine and public health sciences at the University of Rochester Medical Center... >> So, one of the things we like to talk about is to distinguish between the impacts of individual racism and structural racism.

>> ...and Dr. Robert Roswell, a cardiologist and Associate Dean for Diversity, Equity & Inclusion at the Hofstra/Northwell School of Medicine.

>> So, when we look through an equity lens, not an equality lens, we really have to restructure our healthcare system.

>> And I'm Joan Lunden, and it's all coming up on "Second Opinion."

♪♪ Addressing health disparities is increasingly important as our population becomes more diverse, and never has the disparity to access in healthcare become more obvious than with the pandemic of COVID-19.

And we welcome everybody here today.

I want to start with the most basic thing -- how do you define health disparity?

It's a phrase that we're hearing now, but I don't know if everyone understand exa-- How do you define it?

>> Well, when we think about health disparities, we are often thinking about the fact that certain people in our population die younger than other people in our population.

But in addition, there are many, many other factors that differ between races, between other groups for various reasons.

I think today we're focusing on racial disparities, but it's very important to remember that there are disparities not only in healthcare -- which we often focus on, what happens to you once you try to access the healthcare system -- but there are also disparities in health, and the determinants of health are a broader spectrum of factors that we refer to as the social determinants of health.

>> And so that -- I mean, we are focusing on the racial differences, but so that people understand this, there are other factors.

What -- gender, age?

What are some of the other factors that play in here.

>> There are many other factors that can lead to variations in care and variations in outcome -- education, the behavior of the patient, the advice of the provider.

But I think "Nana's" point is that, when we're talking about racial and ethnic disparities, what we're talking about are unwarranted variations that cannot be explained away by those other factors, that have to really be reduced down to simply questions of the race and the ethnicity of the patient.

And we have known since 2004 and the Surgeon General's report that racial disparities are real.

And they have to be confronted.

>> And you see it from, like, statistics such as life expectancy, right?

>> Absolutely.

>> Something as basic as that.

>> Here in the City of Rochester, we can absolutely look by ZIP code and see differences in premature death that are as great as eight years of premature mortality.

And it is unfair that we should allow ZIP code to be a larger determinant of life expectancy than one's genetic code.

>> And there's a lot of things -- Dr. Roswell let me bring you in here because -- that play into why there's such a disparity in longevity, and a lot of that is that there are chronic illnesses that are much more prevalent -- are they not?

-- in black and Hispanic and a lot of ethnic groups, and why?

>> Right, I think that the question is why.

>> Yeah.

>> There are differences in the prevalence of hypertension or diabetes that you have in different neighborhoods, but I think, if you drill down to why those differences are there, you get to see what we are all talking about, which are the social determinants of health, which are buried, really, in structural inequities, structural racism, and also interpersonal racism.

If you think about particularly hypertension and looking at the correlation to how much stress an individual experiences in their community, there's an absolute correlation with that, and that comes with racism.

And when you look at the communities and see that there are differences by ZIP code, you understand that these determinants that we're talking about really determine how long you live, and it's based on where you live and what ZIP code you are and what resources you have available to you -- employment, education, which turns into financial capital and other opportunities.

>> Joan, I'd just love to build on Robert's point of what we know from the work pioneered by Dr. McGinnis and the social determinants of health is that health outcomes are not determined by genetics or the healthcare system, but by environment and behavior.

And in the City of Rochester, the ZIP codes that are home to 25% of the county's population, primarily poor and of color, are the ZIP codes that are home to over 50% of the tobacco-selling retail outlets.

>> Wow.

>> So, if we want to wag our finger at why people are smoking, we need to be very conscious about what we've done as a society to make smoking ubiquitous in their environment, and I think that's the conversation that we really need to be highlighting as we seek to address health disparities.

>> And Rochester isn't unique, right, I mean, if you look at the national numbers.

>> So, one of the things we like to talk about is to distinguish between the impacts of individual racism and structural racism, and when we talk about individual racism, we mean people being treated badly because of the color of their skin.

And we know that that happens day in and day out in huge ways and in tiny ways, but in every instance, it hurts people.

On the other hand, we talk about structural racism, which is really all the ways in which racism has impacted our society, whether it's redlining, which forced people to live in certain neighborhoods, whether it's lack of access to healthy food, whether it's lack of access to physical activity, tobacco.

There are so many different instances where we can see that our society was racist and created an environment that is damaging to people.

>> And it's not just lack of healthcare.

Is it not, Dr. Roswell, that there's also a difference in the quality of healthcare in addition to access to it, am I right?

>> That's correct, and I think I just want to add on to what Nana was saying, is that, you know, if you look at the ZIP codes and how much of where you live actually contributes to your health outcomes, and that's 80%.

So 80% depends on your environment, what hospitals that you have access to, your employment opportunities, and how much money you make.

>> And I imagine even lifestyle disparities -- like, what about access to places to go out and safely feel like you can even exercise?

>> I appreciate your recognition of that, Joan.

It is very clear that the decisions around safety, the lighting that exists in the evening in neighborhoods, the quality of sidewalks and streets have a lot to do with determining who has active leisure time and who has sedentary leisure time.

The choices that people make oftentimes are simply reflecting the choices they have.

>> I think one of the things that's very complicated in this whole discussion is the impact of poverty.

We do know, however, that race plays a role at every level of income.

So, it's not just poverty.

Sometimes people like to think that the reason that there are racial disparities is just because African-Americans are more likely to live in poverty, but that is not the only factor.

There are racial factors that also contribute, but separating out the impact of poverty and the impact of race can be very complicated.

>> And how about even education, Dr. Roswell?

Do we see that that also plays into it?

>> Yes, that also plays into it, and when you look at the studies -- David R. Williams has done this a lot and with all of his studies looking at education, race, ethnicity, and socioeconomic status.

And what he developed is the Everyday Discrimination Scale and measured it in different neighborhoods and found that blacks and Hispanics have higher self-reported rates of feeling everyday discrimination.

And because of that, that is associated with increases in cortisol, increases in dopamine and norepinephrine, increases in other stress hormones that cause visceral and abdominal fat, which is really the precursor to diabetes, increase in coronary artery disease, so all the discrimination that you get.

Even if you are in House A as a black person and House B as a white person, the discrimination you feel in that society really reflects how you then lose years of your life compared to your white neighbor.

>> So, to me, then, the other obvious question is, what if you have a black person who is well-educated and wealthy?

Is there then no disparity, or is there still the disparity?

>> The disparity still exists.

>> Really?

>> And I think Robert's point was not only correct but evocative of Dr. King's observation that discrimination is a hellhound that pursues the black American in our society today.

And those social experiences, those economic stressors are just as real, and income is not fully prophylactic against that.

>> So even if you have a black family, lives in a wealthy area, they're well-educated, have great jobs, they still have less longevity?

>> Yes, when you look at different socioeconomic status levels and you look at the highest level, which is the most educated, highest income, you still see disparities for African-Americans.

And I think a lot of that is based on individual racism.

They have less of an impact, probably, of structural racism, but there is still individual racism.

My friend who is an African-American woman and drives a very nice car gets stopped frequently because they think it's not her car.

>> I have permission to say from my son, who was held at gunpoint by the police department in the snow, in the middle of winter because he fit the profile of the suspect for which they was looking -- he was a young black male.

>> Dr. Roswell, what about a person who wouldn't consider themselves racist, but still a different perception that they might not even be aware of?

>> Absolutely.

So, if you're talking about individual racism, that's things that -- you know, and you can think about it explicitly and consciously if you're aware of it, but then there's also implicit bias, and we have a lot of data on how that impacts healthcare, health outcomes, and healthcare disparities.

So you can be a well-intentioned person, but by living in America and absorbing our culture, those implicit biases can really impact health outcomes, and that's what we're trying to do with the whole medical workforce and we also try to do with medical education, is showing how your mind could actually have you not order a test for someone and impact their life.

>> And there's also mental health.

This is also impacted because the feelings and the stresses that people are dealing with in low socioeconomic areas are very different from the rest of us.

>> Very much the case, and I'd say that it is the most stunning finding from the regional survey work that we have done on health, is to really surface the importance of addressing mental and emotional wellness.

What we found were very significant differences in the reports of helplessness, the feeling that comes from having too much month and not enough money.

>> Yeah.

>> We saw significant differences by race in self-reports of feelings of anger, when you just get sick and tired of being sick and tired, and real differences in reports of self-destructive behavior or destructiveness towards others.

And I think the milieu in which we currently are living is answering the question of what happens to a raisin in the sun.

Sometimes it doesn't just wither.

Sometimes it explodes.

And I believe we have to be very, very focused as a society on addressing the mental and emotional health needs of our African-American neighbors.

>> Another huge determinant of your health status is your health behaviors, and you can imagine that, if you don't know where your next meal is coming from, you're not really worried about whether it's vegetables or not.

And, similarly, if you're worried about whether you're going to be able to pay your rent, you're also not worrying about whether you got your 10,000 steps a day.

So those behaviors and tobacco, which we had raised before -- I mean, tobacco is used largely as treatment for anxiety.

And so you can imagine that those behaviors are not attainable if you don't have a certain level of security in your work and in your home life and in your transportation and in your childcare, and the list goes on.

>> Dr. Roswell, let's just talk, though, about the healthcare system.

Like, I might go in, and a $20 co-pay, I might say, "Oh, that's great because I don't have to pay the $145 or whatever for the medication," but for somebody making $20,000 a year, that $20 co-pay could be the difference of paying the lighting bill.

>> Exactly, Joan, and thank you for bringing that up, because this is how I think about equity versus equality.

So, equality is ensuring that we all have medical insurance, and we're still struggling with that to this day, but to ensure that we have medical insurance and maybe your co-pay is $50 or $75.

That's equality, just making sure everyone has the same thing, but equity is really ensuring that people have the opportunity and ability to reach those same and similar health outcomes.

So, if I'm making $20,000 a year and my co-pay is $175 or $50 and someone is making $200,000 a year, that's not gonna give you the same access and the same chances, because as you said, you have to decide between paying a light bill or another bill.

So, when we look through an equity lens, not an equality lens, we really have to restructure our healthcare system.

And I think our healthcare system is one of the main drivers of healthcare disparities, where structural racism and structural inequities are interwoven through many policies, many procedures, how we get reimbursed.

It's all in there, and I think it really will take a lot of leaders addressing the structural racism and inequities in our healthcare delivery models to actually start moving forward and moving towards health equity.

>> What I'd like to propose is that we need policy for our whole system to change.

Essentially, if we don't get back to the social determinants of health and the prevention of disease, we can't even have any impact on disparities, because the healthcare system can only do so much.

>> Yeah.

>> And so we really have to look at those previous factors that contribute to the development of disease, and other countries do this.

>> Amen.

>> We have a completely different system compared to other countries.

Other countries have better outcomes, and the reason they have better outcomes is they spend much more on social systems and a bit less on healthcare systems, and they are able to get the right ratio so that they're truly supporting improving the health of their populations.

>> Alright, you're saying amen, so what are -- >> [ Laughs ] >> Yes.

>> I always like it when he does that.

>> [ Laughs ] >> Then what can we learn from them that we can reasonably deploy here in our country?

>> I think it is the understanding that health is not derived from the medical system.

Health is derived from the community, and it is the courage to say that making investments in housing and neighborhoods and schools, those are not issues of welfare.

>> Yeah.

>> Those are sound investments that make for a healthier population and result in a more perfect union.

>> Could part of a strategy be more public health information, like really getting to the communities that need it, Doctor?

>> Yes, I think if you can actually get to the communities, but you have to sort of have outreach to those communities.

I think that also takes a lot of training because you can't just go into a community and say, "Well, this is what we think is good for you."

You have to have that cultural humility and have the competence to actually connect with those communities, because communities of color, as we all know, there's a lot of mistrust in the healthcare systems.

So even if you build in the community, you have to regain that trust.

And then you have to have a great outreach, a longitudinal program, so not that you're just dropping in the community and leaving, but you have to have a presence in the community, and that's what health systems are trying to do now.

And so what we're doing at Northwell, for example, is using faith-based organization, so churches, spiritual centers, and interweaving healthcare through those organizations because that's organizations that the community actually trusts.

I think, unfortunately, and in this climate, healthcare is not a trusted entity at present.

>> Joan, that's where I would give Robert one of my amens and say it is absolutely having a longitudinal view of this work, that it cannot be flash in the pan and it can't be fad of the moment.

If we are going to make a difference and eliminate health disparities, it will be by, as Dr. King said, tireless, persistent effort.

I think the second thing he said that was so very important that I'll emphasize it for the viewer is the reliance on thought leadership within the community, particularly within the black community, that the investment in voices and the actions of folks who are trusted and who are knowledgeable is key to the partnership Nana and I have built over the years here, that we rely on each other's expertise.

And then the third thing that I would say, which is just as important in his comments, is recognizing that a crisis is such a terrible thing to waste.

>> And we can't underestimate this mistrust which comes from a long legacy of discrimination in the country, but that mistrust will keep someone from ever even going for any old checkups or, even if they're really sick, will keep them from going into the doctor until they're really, really in trouble.

>> We've been doing programs in our community now for probably about 20 years, and just to underline what both Wade and Robert are saying, you can't do this without engaging the community and without it being led by the community.

And, really, we have to engage with the community, we have to find community leaders, and we have to partner with them and make it clear that we value and honor their community expertise.

And if we don't do that, we're lost -- it's not gonna work.

>> And it's so difficult, because as a black male physician, when I approach patients of color for, let's say, NIH research trials, they say to me, "Well, we will trust you.

You're a black person, so you understand what we're going through.

But what's really going on?

Because we can really talk to you and understand what's really going on behind the surface."

And there's so much mistrust.

I have patients who I'm trying to enroll right now in trials, and they just do not -- they're like, "I understand that you're a black physician, but I'm gonna pass on voluntarily enrolling in these trials."

It's just a very difficult thing to do right now.

People just do not trust medicine, the medical-education hierarchy.

And the last thing I would say is, "Why should they?"

Because I am talking about structural racism, and do all of my colleagues understand, when patients present, what their social determinants of health are and how structural racism impacts those patients?

So, until all physicians could actually see all of their patients through their individual lens, it's hard to really gain that trust that you understand my journey if you don't even know what structural racism or inequities are and you don't have the actual ability to actually relate to me as a person of color.

>> Well, we can't say that that mistrust is unwarranted, due to the legacy of racism in this country, but I think I'd like to end by saying I think the important thing right now in our time is that a crisis is a terrible thing to waste.

>> Amen.

>> That was terrific, and I think I'd like to end there on that note, and thank you all for being on the panel today, because I think everyone in America realizes that this now that has come into focus so much is something that we really need to start addressing and be forward-thinking.

So, thank you all for joining us, and of course thank you for watching.

You can find more information about this series at secondopinion-tv.org.

You can also follow us on Facebook and YouTube, where you can watch today's episode and much more.

From all of us here at "Second Opinion," we encourage you to take charge of your healthcare.

I'm Joan Lunden.

Be well.

♪♪ ♪♪ ♪♪ >> When our communities need help, Blue Cross and Blue Shield companies step up with partnerships capable of preparing meals for thousands of families in need, because it's not just about health insurance.

We believe it's our responsibility to expand care to rural communities, protect our heroes with safety equipment, support local nonprofits.

These are our stories to help build stronger communities for the health of America.

>> "Second Opinion with Joan Lunden" is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.

♪♪