So, we're going to start our next session looking at issues of equity in endoscopy. My co-moderator is Dr. Matthew Whitson, who is a program director at Northwell Health, and I'll have him take the podium to introduce our first speaker. So, it's my honor to introduce Dr. Julius Wilder, who is an assistant professor of medicine at Duke University, and Julius will be speaking about social determinants of health and impact on access to endoscopy. So, Dr. Wilder, come on up. Good morning. I hope you're all doing well. Thank you so much for the opportunity to come here and present. I'd like to do something a little different. I will certainly speak to p-values and statistics, but thinking about the group today, I wanted to do something that really impacted your overall viewpoint and understanding around social determinants of health. I know not all of you spend a lot of time doing this research, but hopefully, with this talk, you'll begin to rethink the way you approach the idea of social determinants of health and health disparities and health equity, and then maybe even rethink about how, in your practice at your home institutions, how you might begin to think about ways to address these issues when you get back home. These are my disclosures. None of these are really relevant to this talk. Whenever I do a talk, I always show one of these. I think this is important for a number of reasons, but for two main reasons. The first is that oftentimes, when having conversations around things like social determinants of health or health disparities or health equity, we confuse equality versus equity. Equality is what we have in this first box. You can see everyone is sitting in the same section at the baseball game. Everyone is sitting on the same or standing on the same box. Everyone is standing behind the same fence, but you can see that not everyone in this picture, the first one, is starting in the same place. This is what happens when you start treating people with equality. This poor short guy can't see anything. If you come to the middle box, this is where we talk about equity. Equality is often where we begin in many aspects of society, particularly societies like ours where you have issues like structural racism impacting things from the beginning. That's where we are typically in medicine, that first box. That second box is speaking to equity. Here we have taken on an equity approach to addressing the fundamental problem, seeing the game. We provided these boxes to help the short guy see. As a short guy myself, I can appreciate that, but let's talk about what that equity cost is. This is anyone who has ever had to create policy at an institution, anyone who has ever had to present policy at a local, regional, or national level, anyone who has had to think about how you distribute resources. This is what comes into play when you think about health equity as well. How long do those boxes last? How strong are those boxes? How many people can you fit on those boxes? How much do those boxes cost? What's the cost if someone falls off those boxes? Equity is certainly something that we strive for often in medicine. It's often the best we can get today, but I would argue it certainly should not be our finish line because of the questions I just raised. Long-term, equity is not always the best sustainable solution. That's why this third box is so important. Again, I said two things. The first thing is understanding equality versus equity, and in the final boxes, speaking to what I think we need to also begin to think about is our ultimate goal should not necessarily just be equity, but it should be addressing the fundamental cause of the problem in the first place. Get rid of the damn fence. That's how you fundamentally address the problem in a sustainable way for everyone. As we think about social terms of health today and we have this little short conversation, we'll talk about those typical things, but as we do it, I want you to think about it in a different way than maybe you have in the past. We always speak to education and income. We talk about insurance and healthcare access. We began to mature in our conversations around social terms of health to include things like conversations around neighborhood and community context, and these are all very, very important things, but the problem when we think about social terms of health typically is that we're thinking about these things and having conversations about these things and doing research about these things in very linear ways. The problem with that is that we're trying to define these conditions acting on single diseases or single mechanisms or single points in time, but they really don't behave in that way. We're trying to define very complicated processes that affect multiple diseases through multiple intervening mechanisms differently over time, and if you don't recognize those differences, if we don't begin to shift our mindset around social terms of health, we will continue to do research that's good for publications but not as impactful, and we'll continue to create policies that in the short term may be helpful but not sustainable in terms of impact. My PhD was in medical sociology, and so I love these kinds of talks because I can geek out about the things that I find really interesting, and they're actually theories that are similar to our sort of approach to social terms of health that do a better job of helping us think about these issues in a much more appropriate way, and that's important, again, when you think about the research you want to do, and we'll talk about that in terms of solutions down the road here, as well as the policies you want to implement, and so I actually am a big proponent of the fundamental cause of disease theory, okay, and here, while I'm using lines, it is not a linear approach. It recognizes the importance of history and time and the role of something called a fundamental cause of disease, a much more distal entity, often a social determinant of health, that acts on multiple disease outcomes through multiple sort of interventions or mechanisms over time, and those can change over time in terms of their impact, and the lines here really can go both directions, and the type of risk, for example, here, behavioral, biological, or social can interact with each other, but this is actually, I would argue, a much better approach when beginning to think about how you might want to understand social terms of health and health disparities and health equity when you want to begin to do research on these issues, and certainly, if you want to begin to think about ways at your institutions how you can begin to address issues around health disparities, and this is a very popular sort of theory that was born out of the authors, Link and Phelan, that is sort of a tenant of social epidemiology and medical sociology. Now, ecosocial theory, and this is where I'm really geeking out as a sociologist, is my favorite. It really actually combines sort of social terms of health, the way we think about it typically, with fundamental cause of disease theory, but it also adds two important things as we begin to understand health disparities. It speaks to the importance of life course perspective, and when we say life course perspective, we understand where you were born, the timing of when you were born is important, and your sort of overall life course, and as you hit different points in life and how that impacts your sort of trajectories are all very important in terms of your overall health. It recognizes the importance of life course perspective, while at the same time, it also considers the role of other sort of higher level issues that we don't often consider in our conversations, like the political context of where you are, what it means to be who you are in that point in time with respect to things like health policy, and so I share this first part of the talk so that we can begin to certainly acknowledge the importance of social terms of health, and we're going to talk about those in a second, but as we talk about these, don't think of them in linear ways. You know, think about, you know, how these factors all come together, recognizing it's not just one thing acting on one thing, but it's really the real reason why we see such persistent disparities in this country and around the world, because these factors are acting through multiple intervening mechanisms, often multiple things on one single individual, and the impact of the individual can change over time, and as you think about your research or, you know, initiating any kind of sort of policies around these issues, keep that sort of mindset, and so let's talk about how this plays out in our practice. What does it look like when we talk about these social determinants and fundamental causes of disease, and the data is quite rich, and we'll spend a little bit of time talking about it, but you know, we know, for example, that class plays a significant role with respect to outcomes among individuals with IBD. Here we're looking at data, looking at Crohn's disease and UC, where it's been shown the impact that class has in terms of rates of, you know, visits, hospitalizations, ICU, and death, and similarly, they've actually been able to show that one of the complicating things with our IBD patients is the fact that they have, they run into issues around food insecurity, which, of course, we all understand the importance of diet in that setting, as well as social support, which is not something that we talk about very often in GI, but, you know, we do often in epidemiology and sociology, you know, social support to find a sort of both instrumental and emotional, right? Emotional obviously being important, but instrumental as far as, you know, something as simple as a patient being able to get to an endoscopy appointment, and how important those factors are. More examples in IBD, you know, we've looked at race and ethnicity, and we're able to show, particularly among people of color, the impact of things like insurance, and that's, you know, across the board will receive worse outcomes, and along those same lines, we've seen it not just in folks who are black, but also among Asian and Hispanic patients, where oftentimes, because they are not getting the appropriate workup, right, for example, for IDA, there's often a delay, and that delay has consequences, right, in terms of the severity of disease when they present, and the limitation of options, unfortunately, sometimes because of the, you know, advanced disease that they have. And so, as we think about sort of our general practice and what we see, you know, we certainly see these sort of social terms coming into play, and the outcomes, unfortunately, lead to sort of negative outcomes in these various populations. Here, we're talking about IBD, but we can talk about the same thing much more broadly about colon cancer. We're all very aware of the disparities that exist in terms of both the rates of colon cancer. I'll take a second to call out here that when you think about colon cancer, we often talk about the burden of it in the black community, but please recognize that there's new data being evaluated by CDC, and actually, across the board, that's recognizing the growing concerning data around the impact of colon cancer in the Native American, American Indian, Alaska Native population, where we're seeing very scary rates rising. Again, in both those scenarios, in terms of the sort of incidence as well as death from colon cancer, and we really have not done enough research within those populations to fully understand all the nuanced issues. But again, we know the importance of colon cancer screening, and the impact that it can have in terms of preventing colon cancer from developing. That having been said, once again, we know that these various fundamental causes of disease, social determinants, play a role. In this study, they're actually controlling for all these covariates, and they're able to show significance of sex, and that's because, for many reasons, across the board, we see better outcomes among women, but with respect to both race, education level, income, insurance, smoking status. It's interesting, if you take a step and just sort of think about the first part of this talk, right, where a lot of times, studies will say, oh, so people who are black, or people who have a low high school education, or people who have no insurance, but what we really should be talking about, right, when you think about this issue, social determinants of health and GI, and endoscopy, and you want to think about how you address these issues, where can policy have the biggest impact, where should we really be focusing research? It's not just the one thing. It's the black patient who has no high school education, who has a low income, who is uninsured. That's the person you're seeing in your clinic, right, that never got a colonoscopy, never got a fit test, that were, you know, admitted to the hospital with hematochysia, and you find this ginormous mass in their rectum, right? Those are sort of the low-hanging fruit among that, you know, in this space that we aren't capturing because we're thinking about things in a very linear way, and we're not really focusing our research, policy, or interventions in those spaces where we'll get the greatest bang for our buck, and that's why I want us to sort of think a little differently about how we sort of approach social determinants of health. Now, one way of doing that is here where we begin to think about neighborhood effects and look at things like area deprivation index or social vulnerability index to begin to define sort of a sort of combined analyses of where you are, what it means to be where you are, and how that impacts your health and your access to resources, and with colon cancer screening, for example, they've done this. We've also done this with liver transplantation, and they've been able to show that in the typical spaces where you see higher deprivation, higher social vulnerability, in those settings you also see lower rates of colon cancer screening, and understand those are both within urban spaces as well as within rural spaces. Those are two very different populations, so you're going to be having to address those issues probably in very different ways, but nonetheless both populations, urban and rural, do experience, you know, increased ADI and SVI driving lower access to colon cancer screening. I'm a practicing hepatologist, and so, of course, I had to throw a little liver in here for you guys, and this is what bothers me about this data and data like this is that it's one thing to say a person didn't get screened for colon cancer. Okay, fine. I mean, there's a number of things that you can argue to excuse that, although that's debatable, quite frankly, but when a person shows up with a GI bleed, the idea that they're waiting an unnecessary amount of time before they get scoped is malpractice, quite frankly, and then when you think about the fact that some folks aren't even appropriately getting scoped is scary, but we have data now that shows that these outcomes are happening, right, and so, and this is a real reflection of us as providers, and I think is a call for us to do better for the patient populations that we take care of, and what we find in this setting, again, is the typical sort of social drivers of health, those same fundamental causes driving this differential access to resources. This isn't a matter of, you know, equality or equity. This is a matter of just basic quality care that patients are not getting, so I've got about five minutes left, and I like to spend that time thinking about things that we can do to begin to address these issues. You know, as we reflect on this, you know, we talk a lot about these things. I think, you know, hopefully we can think about more and have more conversations about things we can do to actively address these issues. Now, I do a lot of research and policy work, and so I'll focus in those spaces and speak to some of the things we've done here at Duke. One thing I'll say is we need to change the way we do the research. You know, we do, you know, we use these linear equations statistically to address these issues, and unfortunately that means that we are thinking about things, again, in linear ways that aren't very linear in terms of the way they behave in the real world, and so I'm a big proponent of leveraging qualitative research or at least mixed methods where we leverage quantitative data to understand and contextualize broadly the problems, but we really need to spend more time in GI exploring qualitative work where we talk to people, understand their unique issues. For example, talking about the role of social vulnerability index in neighborhood and access to colonoscopy. We see that within sort of black populations in urban spaces as well as white populations in rural spaces, right, but I promise you the mechanisms are different. If you only look at the quantitative piece to that, then the policy created to address those issues across those two populations, one of them will probably fail if either one of them works, so you have to engage those two populations, understand the transportation barriers that may be existing, you know, in urban spaces that also could be existing in rural spaces as opposed to just an access issue that might be only present in rural spaces and not in the inner city, and so understanding more, you know, contextualizing, asking questions, that is the benefit. That nuance assessment is what you really get when you leverage qualitative work, and I think moving forward we're going to need to leverage more sort of mixed methods in the research that we do. Something that's been used a lot in medical sociology is the idea of social network analysis where you look at an individual, you look at the nodes that attach to them, and they have these sort of in nodes and out nodes and ties and edges or links to the individual and the groups that they are in, and what is the impact of those groups and the direction of those relationships and the strength of those direct relationships, and beginning to understand those nodes and where people sit in the space that they are in in that point in time so that you can begin to create policies that are very specific to that particular group, for example, to address those issues. You can think about COVID and what COVID was at the beginning, particularly in the African-American community, and how that changed over time. You can think about hepatitis C, right, a disease we saw primarily and we still see overall in African-American populations, but how that changed over time, right, due to the opiate epidemic and the populations impacted by that and how policy and initiatives needed to change to address the disparities in that space, and so social network analysis allows you to really sort of focus in on these specific groups and communities, understand the nuance impact of these social determinants of health on them, and how those things may change over time so you can really create, you know, effective policies and do effective research. And then finally I'll say, you know, community engagement is really, really important. You know, we – it's something that I've sort of began to, over the last couple of years, to get to do more of, recognize the importance of it. I think COVID showed us a lot about the potential benefits of community engagement, but I think community engagement really is only going to work in the setting of doing it the right way, and so – and I would argue that endoscopy centers really need to begin to focus on this. We need to think about sort of equitable, authentic, robust community-engaged research where you're building capacity, you have community partners that you're working together with, right, community-based participatory research where they work to define what the research project is, to define what the problem is, and in true partnership you're building it together. Part of that is going to be facilitated communications where you have really meaningful, equitable partnerships and collaboration with the community, and that's not just for an endoscopy center or a division or a department, but really health centers need to be a part of this conversation. And along that same sort of space, I'd say fostering that authentic communications is really important. We ran into this problem with COVID. You know, we need to have transparent, bi-directional communication between community leaders, stakeholders, partners, and academic investigators, and it's really important that that is a true, transparent, bi-directional sort of relationship in terms of that communication around health literacy and whatever health issues you have. We've seen the dangers of what can happen when you have a lot of sort of inaccurate information being pressed into the communities during COVID, and I think we can learn from that not only the advantages of community engagement, but grow from there and improve the care that we provide our patients in that setting by leveraging those resources. So in summary, I hope at the first part of this talk I, you know, dropped a little bit of that, what is that, second semester of college when you're in the spring semester, you know, you get that sociology class. Hopefully you got some of that feel, right? Some interesting theories to make you think about determinants a little different, and that as you think about future research you see or future things you come across, you think about it not so linear, but you think about the sort of multiple ways, right, these factors come into play. Second of all, you know, certainly I spent a little time speaking to the specific things that we know that come into play with the terms of sort of the roles of social health and IBD and colon cancer screening as well as hepatology. And then finally, as you go from here and think about what you take back home, hopefully you begin to think about ways, you know, you can do different types of research, perspectives around social health, and maybe think about ways you as an institution or an entity can be more community engaged around health literacy, around interventions, around access to colon cancer screening or IBD care or whatever it might be that you do back home. I want to thank you all very much for the opportunity to come here and share this information. I want to thank the course directors for the invitation. I look forward to answering any questions you guys may have in the back end. Thank you.

Dr. Julius Wilder

social determinants of health

access to endoscopy

equality vs equity

fundamental cause of disease