National Institute on Minority Health and Health Disparities Director Interview with "Conversations on Health Care," February 2016
We are speaking today with Eliseo Pérez-Stable, Director of the National Institute of Minority Health and Health Disparities at the National Institute of Health. Prior to joining the NIH, Dr. Pérez-Stable spent 37 years at UC San Francisco, serving as Chief of the Division of General Internal Medicine and Director of both the Center for Aging in Diverse Communities and the Medical Effectiveness Research Center for Diverse Populations.
Dr. Pérez-Stable was elected to the National Academy of Medicine. He earned his M.D. at the University of Miami School of Medicine and completed his residency at UCSF School of Medicine. Dr. Pérez-Stable, welcome to "Conversations on Health Care."
Eliseo J. Pérez-Stable, M.D.—Director, National Institute on Minority Health and Health Disparities (NIMHD), National Institutes of Health
Thank you for having me.
Yeah, and it's January and, as we said, Martin Luther King Day and—who once famously said that, "Of all of the forms of injustice, injustice in health care is the most shocking and inhumane," and we're a nation in the midst of transformation, the healthcare systems. But you've spent decades researching the link between ethnic minority status, income, and health disparities. Could you help our listeners understand how health disparities impact specific populations and how entrenched these disparities really are today?
Yes. To understand health and healthcare disparities, one has to conceive of the problem as multidimensional. Begin with is the social determinants of the individual, how poor they are, what kind of education they had, where they lived. The individual's behavior also influences health disparities. Then the environment and the family; the place where one lives influences the individual tremendously. And finally, the importance of biology and how differences in biological mechanisms and how things work in different individuals has become much more clear over the last 25 years.
All of these things interact with the health system. The big change, of course, in the last six years has been the Affordable Care Act, which has increased access. That's just one step towards improving or reducing health disparities.
Well, you've analyzed these issues both as a researcher but also as a practicing internist.
And from a pretty early juncture in your career, it's clear that you understood that health disparities were often promulgated by cultural barriers. And I understand you're a Cuban-American immigrant yourself; maybe you could talk with us about the kinds of barriers that you have identified as most prevalent across the multitude of minority populations that you've studied.
Yes, we have to remember in this era of technology that medicine and health are really about human interactions, and it is the clinician with the patient that is at the fundamental base of healthcare. Patients come from a very broad spectrum. Clinicians tend to come from a much more narrow spectrum. Wealthy people don't usually become physicians, nor do very poor people have the opportunity to do so.
One area of research that I embarked on was language factors. If the patient and the doctor don't speak the same language, communication is impaired. Another more universal one is literacy and use of jargon. So clinicians will have the tendency to fall back on the medical terminology that they learned medicine in and use words that patients, sometimes even well-educated patients, do not understand.
Going into even more sophisticated communication issues is the area of numeracy, where we are using proportions and risks and estimate of events happening that for the common individual is not very meaningful. To say high risk, low risk, or to give it a quantitative amount—a lot of people don't really grasp those concepts.
And finally, the whole issue of culture. There are expectations in culture that vary, and acknowledging that or understanding that at least gives one insight. For example, in some cultures the distance between people has to be maintained; in other cultures it is appropriate and expected that one touch, as the physician has a role in the culture that is of importance.
First of all, the larger context is that you've done a lot of research on a lot of things: 230 peer-reviewed articles, analyzed everything from improving health of the minority and underserved populations to improving cross-cultural communication skills among healthcare professionals. And how do we go about improving the ability of our primary care providers to have dialogue that is relevant with the population? What's your research shown?
Well, it varies according to the issues. Too many times we have physicians or clinicians, nurses included, who just speak a little bit of a language and try to, quote, "get by."
And this is just—we are beyond that at this point. We should have professional interpreters in all of those interactions and this is, I think we now have empirical evidence to support that care is compromised, that quality is limited. The clinicians who speak the language fluently should be evaluated as such so that we know that they're able to do this.
On the other hand, too many times I have seen, particularly among younger physicians, get quickly into complex terminology, and many, many patients are left behind. So being simple is important, and then step it up, and say, "Well, they are more informed, they are more interested in getting more information," and then provide that information. All of this is teachable.
And then a final point relates to the shared decision making. So, frequently a clinician will present to a patient a situation of, "Here is in favor of doing A and here is what is not in favor; want treatment A or treatment B, here's the evidence. What are your preferences?" You know, a lot of times patients will come back and say, "Well, you're the doctor, you're supposed to tell me what to do," and so the balance between that, so still as a clinician be able to give a recommendation. So I think this is an area I think that we don't do enough shared decision making for many situations, but when we do do it I think there's still the element that we need to say, "This is my opinion," and I think sometimes doctors are hesitant to do that.
You were focused for a long time on certain issues specific to the Vietnamese and Latino populations in San Francisco and realized that to meaningfully impact the health of these populations, that communication had to move really to the level of effective marketing. So tell us, what did you learn from the culturally targeted campaigns around public health issues and problems?
So, early on in my research career, we were funded by the National Institutes of Health, the National Cancer Institute, for developing smoking cessation interventions for Latinos. I worked with social scientists, and in the process we discovered a number of things related to smoking behavior. Probably I think the most important was this notion of collective values for the Latino community.
At the time, this is mid- to late 1980s, all of the smoking cessation literature focused on behavior change for the individual. We found that for the Latino population, they actually had a heightened concern about the collective value, so quitting for your children's sake, for your family's sake, and worrying about having bad breath and not looking good and—which fit with a Latino cultural script that had been described by social psychologists, called simpatía, of wanting to please.
My colleagues worked on the Vietnamese community used what we had discovered in the Latino and applied it to the Vietnamese community and found very similar patterns in that community with, I think they also used the terminology of "health is gold" in Vietnam, health being like gold, and it became their—the marker of their whole program, which continues to this day.
And similar kind of principles were applied to things like getting cancer screening tests, but also needing to have access where we now began to interact with the healthcare system and being able to have to pay for it or have a place to go or have insurance to cover it. So I think the messaging may need to be adapted or tailored to the population, and some level of tailoring has become now a standard approach.
We're speaking today with Dr. Eliseo Pérez-Stable, who is the Director of the National Institute of Minority Health and Health Disparities at the National Institute of Health, where his focus is on supporting research to improve minority health, as well as eliminating health disparities. Prior to joining the NIH, Dr. Pérez-Stable spent 37 years at UC San Francisco, as chief of the Division of General Internal Medicine and director of both the Center for Aging in Diverse Communities and the Medical Effectiveness Research Center for Diverse Populations.
Dr. Pérez-Stable, you focused much of your research on how to improve care and eliminate health disparities not only in the United States, but in many Latin American countries. You were talking earlier about where you live is a good indicator of how your health might be; is there analogous health equity index measure in Latin America in the context of how well they are? And how does disparity play out in those regions, and how are you able to make an impact in places like Argentina?
Yes, I would say that as global health becomes better across the entire spectrum, importance of place is heightened. All of Latin America is what we would call middle income; a couple of them are emerging—Brazil and Argentina in particular, Chile as well—emerging economies that are actually upper middle income. So once you reach that level, then the global health problems go beyond childhood diseases of immunization or infant diarrhea or respiratory infections. Now these may still be problems, but they are much better managed. And in fact, you look at Latin America, and what are the leading causes of death? Well, they are heart attacks, cancer, and stroke, same as the United States.
So in Argentina there are tremendous regional variations. Buenos Aires is a grand capital with a large population with the kind of problems that we would expect in Washington, DC. We did work in the very northwest corner of Argentina, in a province called Jujuy, which is about 70 percent indigenous, a generally poor area. And we worked with adolescent youth in a tobacco project and discovered a couple of things.
Well, first, the patterns of transitions from nonsmoker to smoker among these youth are not that dissimilar from what they are in the populations that have been studied in the United States. The rates were as high or higher, with the typical more boys than girls smoking, and some of the issues such as depression and risk-taking behavior or attitudes playing a role; very little influence of parents and smoking and much more important influence of peer, what you perceive your peers to be.
But we did use the model of health disparities and diversity that we had learned in the U.S. by asking about race, ethnicity, and found that youth were able to say, "Well, I'm indigenous. I am of an Indian background, of native background," or, "I am mixed, or, "I am white, European." And then the traditional pattern has been that the indigenous Americans have been the ones who have been discriminated against and held down, historically. So I think this was a tremendously useful project to carry out and learn about, because the diversity in Latin America as a mixed population of three different continental origins is really quite remarkable, and it represents a unique group to study and learn from.
Well, Dr. Pérez-Stable, you've won many accolades for many things in your career, but certainly you've been noted as an extraordinary teacher and won the highest awards for medical teaching at the University of San Francisco School of Medicine. You're obviously passionate about inspiring the next generation of people who will provide healthcare, which is something we certainly share, and I wonder if you would comment on how modern health professions training is being transformed to address these issues of disparities and to develop the competencies needed to provide culturally competent care, and how are you advancing that work and those ideas at the National Institute for Minority Health and Health Disparities?
Because NIMHD is focused on advancing research issues, this is not at the top of our agenda. We are promoting a diverse scientific workforce; there's a large investment made by NIH, led by Dr. Collins, called the BUILD Program, to enhance the pipeline. I am concerned that in 20 years the population in the United States will be—almost half will be non-white and that the professional workforce is lagging way behind.
On the physician front, only about 10 or 12 percent of entering medical students in 2015 self-identified as not being white. We cannot be so different than the population—not proportional to the population, I think that's maybe setting the bar too high, but we need to move it in the right direction. On the scientific workforce, we face similar challenges, and this is from basic science, biology, research in the laboratory, to population science and behavioral and clinical science.
So I think these are front and center for the NIH. I will note that the NIH did recruit and establish an office, a Chief Officer of Diversity, and recruited Hannah Valantine from Stanford to assume that role.
So she's been in her job now for a little over a year and we've worked together on a couple of projects, and I look forward to continuing to work with her on these critically important issues.
We've been speaking today with Dr. Eliseo Pérez-Stable, Director of the National Institute of Minority Health and Health Disparities at the National Institute of Health. You can learn more about their work by going to nimhd.nih.gov. Dr. Pérez-Stable, thank you so much for joining us on "Conversations on Health Care."
Thank you very much.