Healing ‘broken bonds’: Steps to address racial inequities in diabetes care, education
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The disproportionate rate of diabetes in Black communities coupled with the COVID-19 pandemic laid bare structural inequities that diabetes care and education specialists have an opportunity to change, according to a speaker.
“We are in the midst of an unprecedented time — a horrible pandemic that has exposed racial health inequities, and then the killing of Black Americans that have been very public,” Uché Blackstock, MD, founder and CEO of Advancing Health Equity and former associate professor of emergency medicine at the New York University School of Medicine, told Healio. “People feel paralyzed. These are conversations we need to have, but people wonder: ‘What do I do? How can I make a difference?’ I hope to equip people with strategies that are useful in their own practice to get started on these issues and work toward change.”
Structural racism and health consequences
Racial discrimination across generations — both overt and subtle —has had profound consequences for the health of Black Americans, Blackstock said during an online presentation at the Association of Diabetes Care & Education Specialists annual meeting. Issues such as environmental exposures, stressed diet and lifestyle can all induce changes even at the epigenetic level, determining which genes are turned “on” or “off” and influencing health outcomes, she said.
The results can be clearly seen on maps showing high rates of obesity and type 2 diabetes that overlap with areas of high poverty.
“Too often, for chronic medical problems like diabetes, we’re taught as educators and clinicians that it is due to individual choices,” Blackstock said in an interview before her presentation. “But we have the data to show that there are larger social structures at play that influence the diabetes rates we see in Black communities. We know that structural racism is a key driving force of social determinants of health. Where you have poverty and inequality, you see higher rates of diabetes. That is because of lack of access to health care and healthy foods.”
How to intervene
Addressing systemic racism and health inequality goes beyond education and counseling, Blackstock said. Diabetes care and education specialists must be aware of the socioeconomic factors at play that influence everyday health decisions their patients make, ask more questions and listen, she said.
Blackstock offered a “structural vulnerability checklist” for specialists to use when meeting with patients to better pinpoint specific needs:
- How do you make money?
- Do you run out of money at the end of the week/month?
- How long have you lived/stayed at your residence?
- Is the place you live/stay clean, private and protected by a lease?
- What do you eat on most days?
- Do you have cooking facilities?
- Can you read? In what language?
- What level of education have you reached?
“When you talk to you patient, let them talk more,” Blackstock said. “Let them explain the situation they are in. Instead of the biomedical model, what is the patient’s interpretation of what is going on? With the structural vulnerability checklist, you can find things out like, are they having issues with finding a place to cook their meals? These are things to incorporate into conversations with patients.”
Institutions may also not always address patient needs, and specialists can work to further build trust with community members by holding listening sessions, town halls and focus groups to understand community needs.
“We have a job to heal those broken bonds,” Blackstock said. “I encourage institutions to partner with community organizations to work on structural issues outside the clinical setting.”
Structural frameworks can also inspire structural interventions that can operate at multiple levels, Blackstock said.
“At what level do you want to intervene and make a difference in your patients’ lives?” Blackstock said. “Community building is going to be a very important part of the work you continue to do. Think about one or two specific actions you will take, what barriers exist for each of the action steps and how you will navigate and address these potential barriers.
Our jobs are to improve the conditions of daily life for our patients. Part of that is thinking more broadly about social structures that have led to the inequities in our patients’ lives, thinking about how resources have been inequitably distributed, measuring the problem, evaluating action and expanding the knowledge to develop a workforce — us included — who understand the social determinants of health and what drives them.”
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Blackstock U. Mobilizing for health equality. Presented at: Association of Diabetes Care & Education Specialists Annual Meeting; Aug. 13 - 16, 2020; (virtual meeting).
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