Michelle | michelle ko md phd

Equity and inclusion for our future health workforce: What can we do right now?

Image

The UC Davis Food Access Map shows food and resources on UCD Campus and surrounding community

When we talk about diversity, equity and inclusion, there’s a lot of emphasis on diversity, and less so on equity and inclusion. Sometimes they sound (and in policy, are treated) as an afterthought. Sometimes it feel vague- what do we mean by “equity” and “inclusion”?

For the future health workforce, in higher education, one critical component- the bare minimum- is ensuring students’ basic needs are met, so that they have the opportunity to participate in education itself. Or in other words, what is the point of admitting students to college or graduate school if we can’t guarantee they have enough to eat, a place to live, to pay their bills, or get healthcare when they need it?

We surveyed “under-represented” (including first-generation, low income, racially and ethnically minoritized, students with disability, sexual orientation and gender identify minorities) pre-health students from 2020-21, and found:

Over half had trouble paying rent and bills
One quarter went hungry because they didn’t have enough money for food.

What does that mean for their professional and educational aspirations?

Nearly 3/4 had concerns about the costs of attending and applying to graduate school in the health professions
Over 60% reported: application fee waivers did not meet their cost needs, that fee waivers did not help them apply to more programs, and that fee waivers did not arrive in the time needed.

Since the onset of the COVID-19 pandemic, the widening gap in economic inequity has been weighing down upon our future health workforce. While education programs have traditionally focused on academic preparation, mentorship and admissions, we need to be mindful about both their basic needs, and then how our own programs and policies are creating barriers.

Students who need to search for their next meal cannot perform their best at school– nor do they have the financial resources to take standardized tests, submit multiple applications, and for those who need them, get assessments and approvals for accommodations. The processes for applying for, and receiving, fee waivers, as well as the amount, if any- needs to shore up these gaps, not create more barriers.

Reducing financial precarity is critical for ensuring equity- and creating inclusive institutions.

*For more projects on student basic and economic needs, check out Student Affairs page.

Racism and peer review: When your “peers” are not your peers

Image

Following George Floyd’s murder and the ongoing racial justice movement, funders and journals in public health announced a slew of new opportunities specific to anti-racism, structural racism, and so on, suddenly feeling the urgency to acknowledge that racism has been killing Americans…since, well, the beginning.

These were important first steps in recognizing how scholars have been shut out of research and academia- but these opportunities were still built off the existing research enterprise infrastructure. Which- no surprise- is racist in its construction.

How so? Besides systematically denying funding and publication on racism and health, to scholars racialized as non-white, we also have:

Systematic underfunding/disinvestment in minority serving institutions, including Historically Black Colleges and Universities- thus less support services for scholars at those institutions and lower ratings on institutional environment (in grant review)
Ignorance (deliberate or intentional) of scholarship particularly those with a critical stance (eg devaluation of the work in ethnic studies, critical race theory and extensions)
Denigration of methods of those scholars, as well as other methods e.g. all of qualitative research, community-engaged work, etc
Lack of diversity and advancement within academia

To name a few.

These conditions have led us to the present conditions which we have new funding and publication mechanisms, reliant upon a traditional peer review system in which reviewers are poorly qualified- and at times oppositional- to any work on racism. Furthermore, editors are not necessarily equipped to identify or mitigate low quality peer review. This is just one pillar of the racism within research.

What happens when you just stack new objects on the same old foundation?

Check out the Health Affairs Forefront essay on the poor quality of peer review and consequences: Peer Review and Structural Racism.

Structured travel time and distance inequities in access to hospitals in the U.S. South

Image

White sign covers the existing sign of in front of a hospital and says "This hospital is CLOSED, if this is an emergency call 911." The sign is flanked by shrubs and lamps posts.

In 2019, a PhD student in medical geography at the University of Illinois posted on Twitter about her interest in studying rural hospital closures. An assistant professor from UC Davis DM’ed her to say, we should talk! They met up at a cafe near the AcademyHealth Annual Research Meeting in Washington, D.C. And a speedy 4 years, many datasets, analyses, a move, a new baby later…they finally published the first analysis.

Following up from her previous conceptualization on time as a social determinant of health, Arianna M. Planey uses the cases of access to acute care hospitals in the U.S. South to illustrate the construction of racialized inequities in healthcare.

In addition to grounding the motivation and analysis in the theoretical frameworks of structural racism and access to healthcare, Dr. Planey’s approach shows the benefits of drawing from geography methods to improve health services research, including:

Methodological improvements:

-Use of a validated hospital dataset that accounts for closures and mergers to determine actual losses of sites.

-Use of travel time/distance as an outcome. Most analyses of rural hospital closures, which use ‘container’ methods, e.g. documenting changes in hospital supply by county. In this manuscript, Dr. Planey examines travel time and travel distance. She shows that the impact on travel time and distance is relatively smaller than simply examining gains/losses by county.

-Estimates from the population-weighted centroids of Census tracts, i.e. not the geographic center (commonly used) but rather, based on where people live within the tract.

–Examination of both nearest and next-nearest hospital. This is a key consideration in rural hospital analyses, as community members have high rates of hospital bypass- for many reasons, including lack of specialty services and distrust of the nearest facility. For racially minoritized communities, the nearest hospital may not offer the services for linguistically, culturally appropriate care, which can include care that is respectful and trustworthy.

Findings: You can read more, TLDR Black and Latinx communities have longer travel times/distances to next nearest and nearest hospitals, despite being less remote than rural white communities.

And…what? you want to see what the impact is on access to care? Stay tuned….

Planey AM, Planey DA, Wong S, McLafferty SL, Ko MJ. Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018. Milbank Q. 2023 May 15. doi: 10.1111/1468-0009.12655. Epub ahead of print. PMID: 37190885