Like many cities across the U.S., Boston faces stark disparities along racial and socioeconomic lines. This problem becomes more apparent when taking a close look at health inequalities that exist between Boston's neighborhoods. For example, Back Bay residents have an exceptional life expectancy of 92 years. Contrast that with a neighborhood such as Roxbury, where residents can expect to live only 59 years. That's a difference of 33 years, only four miles apart. Research shows that factors such as access to health care, affordable housing and clean air can all make a difference in a community's overall health and life expectancy. GBH's All Things Considered host Arun Rath discussed these disparities with Dr. Tom Sequist, the chief medical officer at Mass General Brigham, who is researching ways to close the health gaps the city faces. This transcript has been lightly edited for clarity.
Arun Rath: To start off, tell us a bit more detail about what inequalities you've seen working with city residents and how people are affected by them at the individual level.
Dr. Tom Sequist: There's been a long history of measuring and describing health inequalities in the country. It got a really big spark around 2001 with the Institute of Medicine's "Unequal Treatment" report. Since that time, that large volume of information described these inequities and they span from things like chronic disease outcomes to acute care, and mental and behavioral health conditions. I think, the most urgent fire that happened recently was in the spring of 2020, during the start of the COVID pandemic, when there was really an even more intense spotlight that shined on the fact that we were experiencing dramatic differences in health outcomes at that point, obviously related to COVID-19 infection.
Rath: I know from having worked and reported through the pandemic that it definitely felt like, once the pandemic hit, we were having stories that really hit hard on health care disparities, pretty much every week. Talk about how the pandemic affected things. I mean, it got more attention. Is there a way we can sensibly compare how things are or how they've changed?
Sequist: I think the biggest thing that happened at that point, if we go back to the spring of 2020, is that we were seeing the impacts of social risk factors, structural racism on health care outcomes as they related to COVID-19, but those factors were actually always there going back decades and decades. They were just playing out probably over a longer time period, like related to diabetes complications or heart disease complications, which can take years and years and sometimes decades to see the inequities. What happened in the spring of 2020, is all of this happened in fast forward, like almost like a fast moving train. Within a few weeks you were able to see three to five fold differences in mortality from COVID-19 between communities and between people of different racial and ethnic backgrounds. I think that the rapidity of it and the trauma that everyone was experiencing at that time, that really woke everyone up to how important these inequities are. If you were trying to pull out a silver lining, it really spurred a whole new wave of activity that is meant to address equity, anti-racism, and health care as public health crises. You saw organizations like the CDC call it out as one of the biggest public health crises that we have going on right now.
Rath: If it's a situation where we have these massive disparities over a distance of just a few miles, we got there because it was a situation that developed over decades and decades, as you're saying. Obviously, we don't want to take decades and decades to fix it. How do we even go about taking that on?
Sequist: Well, I think the really important thing for us to first consider is actually just what you cited there. This has been going on for decades, if not centuries, among many of these communities. So, we're probably unlikely to fix this within a year or two, although we have lots of pent up energy and folks who really want to work in this space. We just have to set realistic expectations around how long it will take us to address these issues.
Then the next thing we have to do is to say, "OK, well, why is it going to take us that long?" Because these are really monumental challenges and issues that we're facing here. What that means is that to be successful at this, we need true partnerships and collaboration between delivery systems, between public health organizations, between government organizations, and importantly, between community based leaders and organizations. We need to have those collaborations and coordination at scale. There have been a lot of examples of projects that bring those various stakeholders together, maybe not comprehensively, but a couple of those stakeholders together at a time, and you can demonstrate sort of in a pilot program that you can address inequity.
However, what we really need and what our moment calls for now is to do this stuff at scale and to be impactful and to measure and demonstrate that the programs we develop at scale with this kind of collaboration actually are changing the lives of people who live in these communities. That's the thing that I think would be a really remarkable outcome from the past few years.
Rath: Give us some examples of the sort of things that you would like to ideally be able to to scale up.
Sequist: Well, I think what we should be doing is we should take an evidence based lens to this and ask ourselves what are the leading causes of inequity in health outcomes among our communities? If you look at that, it's very clear that one of the things that consistently is that the cause of health outcomes, morbidity and mortality in many diverse communities is heart disease. How do we comprehensively address heart disease? Part of it is health care system treatment, like health care systems like mine. How do we manage high blood pressure or high cholesterol? How do we manage patients who show up in the emergency department with a stroke or a heart attack? It's actually much bigger than that. We need to think about the fact that, let's say seven to 10% of people may experience cardiovascular disease in the form of a heart attack or a stroke. However, it could be the case that double or triple those numbers have high blood pressure or high cholesterol.
We have to do a better job of upstream managing food insecurity and employment security and housing security, because those things really predict the kinds of diets that people have, the ability to have time to exercise and adopt other healthy lifestyles, which will all contribute to better outcomes. To address that, those aren't necessarily interventions that can be led by a hospital system. We would want to involve public health organizations and government programs all the way up through policy levels, but then also community based organizations who can develop programs like mobile van programs, who can bring the care and the screening and prevention programs to people's doorsteps. We may want to partner with agencies that can provide transportation services so patients can get to their clinic visits. They can have their blood pressure managed. But all of this requires really intense coordination.
I would circle back to what I started with, more evidence based, we really want to focus on measuring everything that we do and making sure that we're having that impact and reducing the burden of, let's say, heart attack and stroke in this case.
Rath: Big problem and it's really helpful to have you break it down like this for us. Thank you so much.
Sequist: Thank you very much.
