Battling Health Care Disparities, with Harvard’s Margarita Alegría, PhD | EDB 234
Margarita Alegría, PhD discusses her work eliminating health care disparities.
(29 minutes) Margarita Alegría, PhD is the Chief of the Disparities Research Unit at the Massachusetts General Hospital and The Mongan Institute, the Harry G. Lehnert, Jr. and Lucille F. Cyr Lehnert Endowed MGH Research Institute Chair and a Professor in the Departments of Medicine and Psychiatry at Harvard Medical School. The Disparities Research Unit (DRU), part of the Department of Medicine’s Mongan Institute at Massachusetts General Hospital, is dedicated to undertaking innovative, collaborative research projects that focus on understanding and improving health services, and eliminating health and health care disparities for diverse racial and ethnic and/or immigrant populations.
For more info: massgeneral.org/mongan-institute/centers/DRU
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HACKIE REITMAN, MD (HR): Hi, I’m Dr. Hackie Reitman. Welcome to another episode of Exploring Different Brains. And today, I’m excited to have Dr. Margarita Alegría, who is the head of the disparities unit at Mass General, up at Harvard there, and she’s going to tell you all of her different titles, because there are too many for me to remember. And as a lowly Boston University alumnus, I have to say hats off to Harvard. And Maggie, thank you for being with us today.
MARGARITA ALEGRÍA, PhD (MA): I’m super excited Hackie, to have an opportunity to talk to you and have this dialogue about disparities. I don’t believe too much in titles, I think the work of our team, which I’m going to be talking to you about really talks for itself, people can actually go to the website, Disparities Research Unit at the Mongan Institute at Mass General and find a lot more of who we are. And I think that’s enough Hackie, I’m more excited about telling you all of all the neat things we’re doing.
HR: Well, let me tell our audience that you’re very humble and modest. And the fact is, you are the real champion of the underdog, and you’re going to explain to us what the disparities unit and how you’re fighting for all the underdogs up there at Mass General up in Boston. And so go ahead and tell us what you and your team are doing.
MA: So I want to start giving all the credit to my team because we are an amazing group of we range, sometimes 24 to 26 people and we’re a multidisciplinary team of psychiatry, psychologists, sociologists, economists, social people and social policy. We’re really a group of people that try to look at the issues of disparities, be it in policy, practice, or service delivery. And what we’re trying to do is improve that service delivery so that we can reduce the disparities. We really do several types of things we just published, for example, a paper in Health Affairs, talking about what policymakers should do to reduce, improve mental health and addiction treatment for populations, including for particularly, populations of color, who have been, amazingly, this advantage in the service delivery field. We do also work on clinical trials, Hackie that has to do with how can we do service delivery for populations with in low resource environments, but that is top quality that people really get the best quality, especially for linguistic minorities, we’re doing a lot of work with people that don’t speak English. We do work with people that speak English, but we have now work behavioral health and disability prevention interventions that we do in English, Spanish, Mandarin and Cantonese. And our hope is that we can really develop models of care that are innovating innovative, but also reduce disparities across groups.
HR: Amazing stuff and and as with so many things, that disparities are now on steroids with these Coronavirus times.
MA: I think Coronavirus was a great way of amplifying the lens of how deeply ingrained this disparities are, and how people don’t have the same opportunities in terms of health outcomes.
HR: Can you speak to a little bit directly about the growing LGBTQ and trans communities?
MA: I I’m very optimistic that people have understood that people should be what they want to be and define their gender identity as they want it. I’m a big believer that we have to embrace people whichever way they want to be identified. And for example, I’m a very big believer that the change in the offering of services for LGBTQ needs to have a whole overhaul. I think the system is very bias does not receive the LGBTQ community in in the Same way as other communities, and the fact that for example, we just opened recently a clinic for LGBTQ how to offer services for people that are transgender and want to have a different type of experience in healthcare. So there’s a lot of evidence that the rejection, discrimination and oppression that we have done with LGBTQ communities has actually affected their mental health. You know, we see spikes in suicidality, spikes in depression and anxiety, because of this lack of valuing people that might, you know, decide that they want to be transgender, or cisgender, or have something different.
HR: Well, now I’m going to try to talk about a different discriminated against minority, those of us whose brains are different, or have disabilities, are you addressing them also?
MA: We are, we are actually now running a clinical trial, Hackie that is to try to deal with people that are showing the first signs of disability, either physically or emotionally. And what we try to do is actually give them the support, they need to be able to thrive and maintain so that it doesn’t accelerate into complete disability. So for example, we have what we call it’s a trial called strong mind strong bodies. And what we’re trying to do with that trial is actually that do combine interventions to interventions. One, that it’s an exercise intervention for people who are showing signs of starting to lose movement, starting to have more difficulty in balance, starting to show the first signs of physical functioning deterioration, and people that also are showing us a combination, either depression or anxiety, we give them this intervention that it’s a combined multimodal intervention of 36 sessions of exercise, which is called invest was developed as invest. And then 10, to 12 sessions of cognitive behavioral treatment together with meditation, relaxation, and communication skills.
HR: And I guess the third leg of that would be nutrition.
MA: You know, we talk not only about nutrition, thanks for raising that, we don’t only talk about nutrition, we also talk about sleep. Because we think all of these things are intertwine. We also talk about the importance of self care in going out and you know, making sure that you have a self care plan that’s tailored to your needs. And to your we actually work a lot with culture and contexts.
HR: Well, that’s good, such great stuff you’re you’re doing. What do you find to be the biggest challenge?
MA: The biggest challenge, I think it’s the narrative changing the narrative Hackie, I think people have made a narrative of why we have disparities, that is very focused on people are just not trying hard enough, or people are not really working, you know, they’re weak, they have some failures, they have some maybe mental health susceptibilities. And I think that that’s a very victimizing the victim mentality that we have supported. And so I think now COVID has helped us see that a lot of the outcomes of the health outcomes of populations of color have to do with what are the offerings for them? What are the decision making things we do for them, for example, when we decided to give ventilators to peep decided to exclude from ventilators, people that had chronic conditions, that actually was a decision that affected people of color, because they’re more likely to have chronic conditions. So that was an example of a decision that was made, probably with a good intention. But actually, it’s a decision that harm people of color at the moment that that was the guideline. So I think like that we make a lot of decisions that are actually harmful to our populations of color.
HR: I would also — you know, it’s interesting because let’s just talk about mental health for a minute. I was asked to be part of the Broward Mental Health Summit down here, and to speak about neurodiversity because most of our psychologist and psychiatrist and I’m an MD doctor, orthopedic surgeon, but which we’re, we’re smart, like bulls, you know, way. MDS get zero training and neurodiversity. So for instance, we don’t know, many people working suicide lines, that if you have high functioning autism, your rate of suicide and attempted suicide is 10 times the average, if you have ADHD, it’s three times the average. And so these getting these educated and getting them access to care is a difficult thing. So I’m sure that your disparities unit is addressing the disabled and the autistic and the mental health issue.
MA: Yeah, we have done some work, for example, and we actually did some simulation work to actually with people that had disabilities. And we did this, this is another paper we published in Health Affairs, where we actually showed what of the social determinants could help people. And we found employment, coaching on employment and support on employment, supported employment, would be something specially for people with disabilities to, to really improve. I completely agree that I think for the first time and given COVID, and also the escalating issues that we’ve had on suicide on the opiate pandemic, and, and all of those things have really shed light on the importance of addressing disabilities, but also addressing behavioral health, because I’ve never seen things. So serious as of now, Hackie, I’m very concerned, especially concerned for young people. I’m very concerned about what we call emerging adults. Because what we’re seeing in the data, and this is been reported in different places. So it’s not one place is that emerging adults 18 to 26 to 27, are having the toughest time. And I think it has to do with cumulative adversity, being tackling them in a way that they are losing hope. And so I think we need to address their mental health issues and and provide services very quickly, especially during the pandemic, where some of them have left school have dropped out. We’re seeing some of them having to work because their families have lost jobs. So this is an area where we should be emphasizing as much as we can, how to get people quickly to help.
HR: What you said that really caught my ear was the causes of these disparities in our the cause of the disease and addressing it and it’s very interesting. The way you put it is that changing the narrative, changing the narrative, which hopefully, we’ll all be able to do together to help one another.
MA: Yeah, I think Hackie if you think about it, one of the biggest problems we have is that the level of institutions that interact with people of color, and I include myself in the health care system, but I also think we have the criminal justice system, we have the education system, we have the welfare system. And if you look, there is so much data now. I mean, this is not even an issue we have to discuss of how people are treated so differently, so differently. And then the outcomes are going to be different because what the input is different, the output is going to be different. And I think we need to do more organizational change. Starting with the healthcare system, this is one of the things I actually gave a talk yesterday on how we have to change the the substance treatment system to look at it in a very different way. Not the way of this are people that don’t want to get better, but rather, we’re failing that what we’re offering out there is not sufficient to get them to recover and reintegrate in society.
HR: If you had a wish list of three wishes at a national level you could get, what would they be?
MA: One of the things that I wish that we would get is more community voice in the actual decision making. I think there’s, we have a lot of people that are distance from the communities that need the help. So that gap between the community and the decision making is large. So one of the areas that I’ve spoken quite a bit is the importance of bringing academic community and policymakers together, to actually make sure that we have the best scientific evidence, the best problem solving from the community and what they want, and policymakers that can tell the boundaries of what can be done or not done. So I think that is like number one.
I think number two is, I definitely would want to change the narrative, the narrative in terms of people being more willing to see how in their everyday interactions, they perpetuate this narrative in a way that they’re not even aware. So I don’t think necessarily people are aware, to me, this is a blind spot that many of us have. Where we make I call it attributional errors that we attribute to people characteristics and traits, to failing the information because we haven’t spent enough time getting to know what what is their life about? What are their opportunities, what’s missing from their lives. So I think that that, to me, is the second one to really have more opportunities to to do less attributional errors and more perspective getting and perspective getting from people to really know what’s needed.
I think that third one of you asked me, it’s probably a change in communities investing more in communities of color and for communities, Hackie. I think we’ve did this invested too much in them. And I think we need to go back and have a really good plan that’s more geographically base. Because we know where the problems are, this is not like science, we just need to map it. And then based on those, that geographical, geographical identification, or where are we doing poorly? What we need to do is how can we invest more on that on that? And, and that’s what I think we need to do. In terms of like, what I think the Biden administration is really thinking about reinvesting in for communities and communities of color. And I think that’s a very good plan, I would really bring the community to make sure that what we’re doing is what they really need, and not what we think they need, is planning with them, rather than for them.
HR: Very well put, and a very creative, some very creative ways around the way to appeal to the private enterprise profit models, through tax structure, tax credits, but also providing services that they’re good customers, there are many different ways. So those enterprise-owned variants and other methodologies of going in there and making that also. On the medical school front is getting the people who are admitted to medical, medical school people of color, especially to serve in these areas, you know, very, you know, right in those areas, which is tough. It’s tough to do, but we have to figure out creative ways to do that.
MA: Well, I think it could be incentivize Hackie, with loan repayment. I think you could incentivize that, you know, by by different mechanisms. We know that doctors of color tend to dedicate more to communities of color, we all we that’s been shown. So it’s more like how do we repay for that service? That it’s like you’re saying we’re difficult sometimes it Really, the infrastructure for service delivery? service delivery is limited. So that’s where I think we could do more. And definitely, I think we’re thinking a lot more of how can we make sure that places like Harvard, like, all of those places really do an incredible approach of embracing and, and, and making our students of color feel like, you know, they belong, we want them, we really need them to help us change the culture.
HR: What are the specific research projects, if you’d care to talk about them that you have going on presently.
MA: So let me start by telling you about a project that we’re very excited about. It’s a project on trying to improve substance use treatment. And it’s, it’s a project that’s funded by the National Institute of Drug Abuse, where we actually are doing what’s called mixed methods, we’re actually collecting we have data from Medicaid, looking at what’s called performance indicators, indicators that suggest that you’re giving good services on substance use treatment. And then we also have a qualitative component where we interview policymakers, administrators of insurance plans, clinicians and patients, and then we join that data and work with the state, we’re doing this in the state of New York, to try to see how between the data we’re finding and the information that all of this stakeholders are giving, giving us, we can do a better job in servicing the population in Medicaid for substance abuse. So we’re actually doing that, and we’re learning a lot. And we’re writing about it right now, and working with the in partnership with the policymakers there.
The second project we have is one that I started talking about, which is on disability prevention, we’re very, we know for a fact that people of color, as you know, they live less, and they become disable, at a younger age. So one of the things we’re very interested is to try to lessen that gap. And we’re identifying people early, that are showing this ability, and actually trying to give them a combined program that has a physical health component of exercise of strengthening a building balance with, you know, best, and steppers. And then we’re doing a program for when they start getting depressed, anxious, you know, how to cope with the stress that they have in their lives, so that they that disability is decelerated. So that’s the second project we have. We also just recently got a project that’s actually, I think, very important, which is looking at discrimination of immigrant populations. And this is with youth. In Indiana. It’s called the Avant Sandow project. We are following 340 families of Mexican American youth in I would say an immigrant a new immigration site that where people are being discriminated and rejected quite wide regularly. And and what we’re trying to see is how the family tries to cope with that discrimination. How does the family so we’re interviewing the child, the youth, the mother and the father or other caregiver, and we’re really following them for three years trying to see how they deal with discrimination and ethnic socialization. And so we’re hoping to learn a lot of how the things happening time so that we can develop interventions for them.
HR: What’s been interesting to me on the way your brain gets wired, the mic what I’ve been learning from, say my friend, Dr. Derrick Macfabe up in Canada, okay. He’s one of the gut-brain microbiome experts in the world. He’s showing the direct relationship between the wiring of your brain — the microbiome almost has more to say than your gene pool. And so you know, a nutritious approach for rewiring your brain. And I’m not talking theoretically now that can measure all that, as you know it all those brain scans and everything. And the same thing goes for exercise now, like your excellent exercise programs, you can actually see the differences. Right? How hard is it to get the proper nutrition to the communities you’re speaking about? Well,
MA: I mean, I think one of the the, the terms that has become more in vogue is the food desert areas that we have in this country. And then the difficulty for people to access vegetables, access, you know, good fruits, and how it really becomes very hard. I think this is something that, like you’re saying, with your program with us giving them food, we know there’s a very strong correlation between food insufficiency and mental health outcomes. That, you know, there is. That’s why giving youth and nutritious free foods is so important. But what one of the things you said Hackie is exactly what we we recently were in a panel on the environment and mental health. And what you were saying is the food deserts, but also that affect, you know, your brain. But not only that, I think we talked about pollution, air pollution, and how that affects. We talked about how not having green spaces, affects because there’s some evidence that you know, green spaces really make a difference. This was with relation to mental health. But there’s now coming so much about how where you live, your context, has so much to do with your health, your brain health, actually, it’s not only autism, we’re finding that for psychosis. And there’s really fascinating data that’s coming out on psychosis related to the environment, Parkinson’s disease, you know, so all of this is really an area that we should be focusing more rather than blaming the victim, as I say,
HR: How can people find out more about you?
MA: I would say if they want to find more about us, because again, I represent a team, I would say to go to the website of the Massachusetts General Hospital, the Mongan Institute, and look for the Disparities Research Unit. There we have a lot of information and people can always there’s my actually my email, and they can contact me if they want, you know, articles or they can actually go to research eight. Almost all my articles are my papers that are there in researchgate so people can feel or contact me to get them. I’m happy to give them out.
HR: Well, Dr. Margarita Alegría, who’s a professor in the department’s of medicine and psychiatry, at the very prestigious Harvard Medical School, and chief of the Disparities Unit at Mass General. And on behalf of your whole team, because I love the way you give credit to you can’t do it without the whole team. Thank you so much for being with us here at different brains and thanks for all you do for so many.
MA: Thank you Hackie, happy to have you.
