NPHR Fall 2024 - Structural Racism

NPHR

Northwestern Public Health Review

Structural Racism Fall 2024 Issue

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N

Siwen Wang Cover Artist

ARTIST STATEMENT When I was tasked with creating an illustration about the implications of racism on access to health care, I wanted to present it in question form instead of giving any direct answers: how does racism affect access to health care? To depict this question in my illustration, I deconstructed it into three elements: underrepresented groups, access, and the healthcare system. I used the key to represent access, and I used the door with the sign of the Rod of Asclepius to represent entry to the healthcare system. The key is glowing and floating in the air, and a lady with dark skin, who represents underrepresented groups, is standing in front of the entrance trying to reach the key. I hope this illustration will provoke readers to think before they open the journal, prompt them to find answers within the articles, and inspire deeper thought after reading the articles.

Siwen Wang is originally from China. She earned her PhD degree in Biochemistry from Purdue University with a concentration in computational life sciences.

Finding that the most efficient way to understand and explain complex biomedical problems is often through visuals, she decided to pursue a MS degree in Biomedical Visualization from the University of Illinois at Chicago. In the future, she wants to help her audience better understand science by using her expertise in scientific research, storytelling, and artistic creation.

NPHR Table of Contents Structural Racism

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Letter from the Editors

Grace Bellinger, PhD, MPH Joo-Young Lee, MD Meilynn Shi

7

Maternal Mortality in Numbers Kimberly B. Laughman, MD Nevert Badreldin, MD

10

Building Health Equity Begins in Childhood Meilynn Shi

16

On Vaccine Hesitancy: An Interview with Dr. Muriel Jean-Jacques Grace Bellinger, PhD, MPH

19

Expanding Equitable Access to Organ Transplantation Dinee Simpson, MD

25

Northwestern Features: CHET, STRIVE, PPH

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Letter from the Editors

Dear Readers, We are thrilled to present the 2024 edition of the Northwestern Public Health Review. This issue explores the health consequences of structural anti-Black racism.

We highlight the work of several Black-American physicians and scholars, along with several programs and initiatives working to achieve greater racial equity.

We, as an editorial board, recognize the enduring harm of structural anti-Black racism in public health and medicine and call on our readership to take actionable steps.

First, Dr. Kimberly Laughman and Dr. Nevert Badreldin describe racial disparities in maternal mortality. They emphasize the origins in anti-Black racism and the social construct of race and offer solutions to address racial

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gaps in maternal mortality. Dr. Nia Heard-

uses

Garris then contributes her perspective

and educational programming to address

as a pediatrician, studying how racism

health disparities and train future healthcare

experienced during childhood impacts health

professionals and public health practitioners.

outcomes. She emphasizes the importance of

The STRIVE program aims to improve access

health equity scholarship in addressing known

to

health disparities and offering evidence-

education by offering medical students

based solutions to policymakers. Both pieces

with

highlight the impact of structural inequities

from residents and fellows who are similarly

on health outcomes.

underrepresented in medicine. PPH began

research,

and

community

representation

marginalized

engagement,

within

identities

medical

mentorship

offering a course on structural racism in 2021, We then include an interview with internal

stimulating discussion and growth among

medicine physician Dr. Muriel Jean-Jacques,

students and faculty. These programs serve as

who addresses persistent racial disparities

examples of how we can address the effects

during annual flu vaccinations. She explains

of structural racism on health and wellbeing

the reasons for these inequities and offers

through training, mentorship, and education.

strategies for combating them, drawing connections to the early stages of the

We thank everyone who contributed to this

COVID-19 vaccine rollout. Finally, Dr. Dinee

important edition, including the students of

Simpson, a transplant surgeon, describes

the University of Illinois at Chicago Biomedical

racial gaps in kidney disease and access to

Visualization program for their incredible

organ transplantation. She describes how

illustrations that accompany the writing

patients fall out of the transplant process due

throughout this issue. We wish to especially

to structural racism and how she founded the

acknowledge the Black scholars, physicians,

African American Transplant Access Program

editors, illustrators, and supporters that

(AATAP) at Northwestern Medicine. Both

brought this edition of NPHR to fruition.

articles comment on community distrust in

Developing this issue during the COVID-19

the healthcare system and offer approaches

pandemic and social justice movement was

for healthcare providers to restore patient-

a labor of love, and we are excited to finally

physician trust.

share it with our readers.

At the end, we also include brief features of three programs and initiatives at Northwestern seeking to address the harmful effects of antiBlack racism in medicine and public health:

In Health,

the Center for Health Equity Transformation (CHET), the Student to Resident Institutional

The NPHR Editors-in-Chief

Vehicle for Excellence (STRIVE) program,

Grace Bellinger, PhD, MPH

and the Program in Public Health’s (PPH)

Joo-Young Lee, MD

coursework

on

structural

racism.

CHET

Meilynn Shi

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Maternal Mortality in Numbers Kimberly B. Laughman, MD Nevert Badreldin, MD

“You’re my doctor?” asked my antepartum service patient, her face

diabetes, and postpartum hemorrhage. They

as compared to their White counterparts.5-7

softening as I stepped closer to greet her. This

also undergo cesarean section at higher

However, several studies have demonstrated

is a reaction I’ve grown accustomed to from

rates when compared to White women in the

that even after accounting for several of these

many patients when they see me, a young

U.S.3,4 Thus, not only are Black women more

variables, poorer outcomes persist.8,9 A large,

Black woman, walk into the room. “I’m scared,”

likely to have complicated pregnancies, but

population-based cohort study by Johnson

she began, “I don’t want to die.” I was shocked.

they are also much more likely to die from

et al. found that among college-educated

Though it seemed obvious to me that this

these

women with private insurance, Black women

routine admission would likely be brief and

counterparts.

complications

than

their

White

experienced significantly higher preterm birth

uneventful, the patient feared she would

rates than their White peers (9.9% vs. 5.5%). The

become a statistic: yet another Black American

difference in maternal mortality rate is even

woman dying during pregnancy.

The patient’s fears were not unfounded. At 17 maternal deaths per 100,000 births, U.S. maternal mortality rates are more than twice that of other high-income countries.1 When examined by race, the mortality rate for nonHispanic White women drops to 13 maternal

Black women in America face many socioeconomic inequalities that contribute to these disparities in pregnancy-related health outcomes.

more pronounced: among those with at least a college education, Black women experience a five-fold higher maternal mortality rate than White women.2 In another study, researchers found that infants born to Black mothers with advanced degrees were more likely to die within their first year

deaths per 100,000 births, but jumps to 41

of life than infants born to White mothers with

deaths per 100,000 births for non-Hispanic

only an 8th grade education.10 Interestingly,

Black women.2 Furthermore, for every maternal

studies have found that birth weight and

death, 100 more women suffer a “near miss,”

Due to long-standing societal structures

gestational age at delivery of neonates born

or a severe maternal morbidity event such as

that perpetuate racism, Black women in the

to recent Black African immigrant women

requiring an emergency procedure or suffering

U.S. are more likely to have worse access to

were more aligned with those of neonates

organ failure. Severe morbidity and mortality

healthcare, less education, lower income

of White American women than those of

aside, Black women are at increased risk of

levels, and higher likelihood of living in a food

Black American women, suggesting that the

pregnancy complications like preeclampsia,

desert neighborhood with limited walkability

root cause of these disparities lies in a social 7

Maternal Mortality in Numbers

Laura Sheehy

concept of race, not a genetic one.11

likely to have a medical condition compared to a White patient, the implied standard.18 These

Artist

Laura Sheehy is a biomedical illustrator who combines her passions for education, medicine, art, and design.

She obtained her Master of Science degree in Biomedical Visualization from the University of Chicago at Illinois. After receiving a Bachelor of Fine Arts degree from the School of the Art Institute of Chicago, she worked as a liaison between clients, designers, and vendors for a decade. Laura enjoys using her clear visual communication and illustration skills to distill complex scientific and medical information into impactful visuals.

In their Lost Mothers series,12 NPR and

educational practices further promote implicit

ProPublica investigated the stories of women

and non-implicit biases and may contribute

who lost their lives due to pregnancy-related

to dangerous misconceptions like those

complications. They write that for Black

identified by Hoffman et al., who found that

mothers, “being devalued and disrespected

roughly half of White student doctors falsely

by medical providers was a constant theme.”

believed that Black individuals are biologically

This notion was reinforced through countless

less sensitive to pain due to “thicker skin” and

examples, ranging from the Florida mother

“less nerve endings.”19 Myths like these have

whose shortness of breath was cast off as

real consequences for Black patients who, as

secondary to obesity while she suffered from

research has demonstrated, are less likely to

pulmonary edema and heart failure; to the

receive aggressive pain management than

Nebraska new mom whose doctors refused

their White peers.20 Unpacking this faulty

to believe she was experiencing a heart

pedagogical framework is a crucial step toward

attack until she had her second one; to the

breaking down racial disparities entrenched in

Brooklyn woman who began bringing her

our field.

White husband or in-laws to every prenatal visit to stave off her sense of “just [knowing]

Another vital part of the solution lies in hiring

in your bones when someone feels contempt

a fuller array of physicians and healthcare

for you based on your race.” These are biases

workers who mirror the population for whom

from which no amount of wealth or education

they provide care. While only about 5% of

can protect Black women. To quote Dr. Joia

U.S. physicians are Black, studies have shown

Crear-Perry, founder of the National Birth

that receiving care from a Black physician may

Equity Collaborative, “Race isn’t a risk factor in

be associated with improved outcomes for

maternal health. Racism is.”13

Black patients.21,22 A study by Greenwood et

?

al. demonstrated that Black neonates cared for by a Black pediatrician experienced a 53%

What, then, can be done about this grave reality?

reduction in mortality compared to Black neonates cared for by a White physician.23 Evidence also suggests that when Black patients share racial concordance with their providers, they experience improvements

The answer, like the question, is complex.

in

shared

decision-making,

medication

First, it is paramount to encourage and fund

adherence, and time spent during visits.24,25

continued research into racial disparities in

Thus, increasing diversity among the obstetrics

maternal and neonatal outcomes, as well

and gynecology physician workforce may

as targeted interventions.14 As healthcare

provide protective benefits for Black women.

professionals, we must also examine how we

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train student doctors and what frameworks

While we work on ways to create a safer

we provide them with to interpret the social

healthcare landscape for Black women, it

context of each patient’s interactions with our

is important to acknowledge the reality of

healthcare system. For example, conventional

disparate pregnancy outcomes that exist in

teaching commonly lists Black race as a risk

the current system. In their 2016 publication,

factor for medical conditions, despite there

the Center for Reproductive Rights and Black

rarely being any biologic or physiological

Mamas Matter Alliance asserted that the

justification

This

healthcare industry must create a culture of

encourages student doctors to look at Black

to

support

this.

respect for the autonomy and decision-making

patients as other: always relatively more or less

power of women in order to better engage

15-17

Laughman, Badreldin patients and improve maternal outcomes.26 Empowering patients to become more

KIMBERLY B. LAUGHMAN, MD is an obstetrician

involved in their own healthcare, providing

gynecologist at the Association for Women’s Health

education on concerning symptoms, and

Care in Chicago. She earned her Doctor of Medicine

assisting

the

degree from Columbia University and completed her

complexities of healthcare systems are

them

with

maneuvering

residency at Northwestern University. She is committed

critical tools to help safeguard against the

to research, medical education, and community service.

disheartening statistics.

The landscape of the U.S. population is rapidly changing. People of non-White race are projected to become the majority of the U.S. population by 2050.27 As the nation becomes even more an amalgamation of

NEVERT BADRELDIN, MD is an Assistant Professor of

races and cultures, it is imperative that we

the Department of Obstetrics and Gynecology at the

find lasting solutions to tackle the maternal

Baylor College of Medicine. She received her Doctor of

and neonatal disparities that impact what will

Medicine degree from the University of Cincinnati and

soon become the majority of Americans.

completed her residency at Duke University, along with a fellowship in Maternal Fetal Medicine at Northwestern University. Her research interests are in postpartum pain management and opioid prescribing.

1. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012 Nov;120(5):1029-36.

2. Petersen EE, Davis NL, Goodman D, et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths – United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68:762-765.

3. Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol. 2014; 210(5): 435.e1-435.e8.

4. Braveman P, Egerter S, Edmonston F, Verdon M. Racial/ethnic differences in the likelihood of cesarean delivery, California. Am J Public Health. 1995;85(5):625-630.

5. Vilda D, Wallace M, Dyer L, Harville E, Theall K. Income inequality and racial disparities in pregnancy related mortality in the US. SSM Popul Health. 2019;9:100477.

10. Centers for Disease Control and Prevention (Wonder). Linked Birth/ Infant Death Records, 2007-2013.

20. Badreldin N, Grobman W, Yee L. Racial Disparities in Postpartum Pain Management. Obstet Gynecol. 2019;134(6):1147-1153.

11. David RJ, Collins JW Jr. Differing birth weight among infants of U.S.-born Blacks, African-born Blacks, and U.S.-born Whites. N Engl J Med. 1997;337(17):1209-14.

21. Adamson AS, Glass DA 2nd, Suarez EA. Patient-provider race and sex concordance and the risk for medication primary nonadherence.

J Am Acad Dermatol. 2017;76(6):1193-1195.

12. Martin N, Montagne R. Lost Mothers: Maternal Mortality in the US. NPR; 2017.

22. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-Physician Racial Concordance and the Perceived Quality and Use of Health Care.

Arch Intern Med. 1999;159(9):997–1004.

13. Crear-Perry J. Race Isn’t a Risk Factor in Maternal Health, Racism is. Rewire News Group. April 11, 2018. Accessed December 5, 2020.

14. Chakhtoura N, Chinn JJ, Grantz KL, et al. Importance of research in reducing maternal morbidity and mortality rates. Am J Obstet Gynecol. 2019;221(3):179-182.

15. Sheets L, Johnson J, Todd T, Perkins T, Gu C, Rau M. Unsupported labeling of race as a risk factor for certain diseases in a widely used medical textbook. Acad Med. 2011;;86(10):1300-3.

6. Howell EA, Zeitlin J. Improving hospital quality to reduce disparities in severe maternal morbidity and mortality. Semin Perinatol.

2017;41:266-272.

16. Williams DR. Race and health: basic questions, emerging directions. Ann Epidemiol. 1997;7(5):322-33.

7. Reeves R, Rodrigue E, Kneebone E. Five evils: Multidimensional poverty and race in America. The Brookings Institution; 2016.

17. Moscou S. The conceptualization and operationalization of race and ethnicity by health services researchers. Nurs Inq. 2008;15(2):94105.

8. McGrady GA, Sung JF, Rowley DL, Hogue CJ. Preterm delivery and low birth weight among first-born infants of Black and White college graduates. Am J Epidemiol. 1992;136(3):266-76.

18. Braun L, Saunders B. Avoiding Racial Essentialism in Medical Science Curricula. AMA J Ethics. 2017; 19(6):518-527.

9. Harper M, et al. Racial disparity in pregnancy-related mortality following a live birth outcome. Ann Epidemiol. 2004;14(4):274-279.

19. Hoffman K, Trawalter S, Axt J, Oliver M. Racial bias in pain assessment. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301.

23. Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physicianpatient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020;117(35):21194-21200.

24. Traylor AH, Schmittdiel JA, Uratsu CS, Mangione CM, Subramanian U. Adherence to cardiovascular disease medications: does patientprovider race/ethnicity and language concordance matter? J Gen Intern Med. 2010;25(11):1172-7.

25. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-15.

26. Black Mamas Matter Alliance. Black Mamas Matter: A Toolkit for Advancing the Human Right to Safe and Respectful Maternal Health Care. Center for Reproductive Rights; 2016.

27. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060. U.S. Census Bureau; 2014.

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Building Health Equity Begins in Childhood Meilynn Shi, BA

GROWING UP, DR. NIA HEARD-GARRIS SAW FIRSTHAND HOW RACIAL AND SOCIOECONOMIC LINES DIVIDED HER NEIGHBORHOOD IN CINCINNATI, OHIO.

Every week, she would take a five-minute

manifested in medicine and healthcare. In

drive to visit either her mom in the north part

one room, she would care for a patient whose

of the city or her dad in the south part of the

family worked in high-level government

city. She soon noticed how her friends on the

positions, and in another room, she would

northside, presented with opportunity and

care for a patient who was living at a homeless

security, only kept climbing higher, while

shelter.

her friends on the southside struggled to find a foothold. Only a few streets marked where

“That’s why I was drawn to medicine,” Heard-

their lives diverged.

Garris said. “What I want to get my head around is not only that there are those

While in residency at the Children’s National

differences, but why they exist and how we fix

Medical Center in Washington, D.C., Heard-

those differences. Namely, for me, that’s driven

Garris continued to see how similar divisions

by structural racism.”

NIA J HEARD-GARRIS, MD, MBA, MSc is a pediatrician at Northwestern University and the Ann & Robert H. Lurie Children’s Hospital of Chicago.

She is the Founding Chair of the American Academy of Pediatrics (AAP) Section of Minority Health, Equity, and Inclusion (SOMHEI). As a Robert Wood Johnson Clinical Scholar, Heard-Garris served as a fellow at the U.S. Department of Health and Human Services, working on the Flint Water Crisis and Zika virus outbreak. Her goal is to bring together her experience in clinical care, research, and business to advance health equity.

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Building Health Equity Begins in Childhood When researchers discover a disparity in

among adult populations, but disparities

health outcomes and cannot attribute it to

begin early on in childhood, extending

any specific cause, they sometimes point

as far back as prenatal care. Many studies

to genetics as the most likely explanation.

have found that structural racism impairs

However, when genetics is used as a proxy for

critical development stages, increases rates

individual- and population-level differences,

of chronic stress, increases the likelihood

particularly ones that fall along racial lines,

of disease and mortality, and increases the

it obscures the role of poverty, underfunded

likelihood of low birth weight deliveries.1,2

public schools, unstable housing, lack of green

Studies have also shown that similar to

space, segregation, racism—non-biological

adults, racial discrimination can affect asthma

factors that then give rise to biological

severity, access to kidney transplants, pain

differences. It falsely blames the individual for

management, and surgical outcomes among

consequences that are shaped not by biology

children.3 The problem is that children are

but by society and its institutions.

often left out of the conversation, in part because they don’t yet have the autonomy to

“For the most part, we are the same genetically,”

advocate for themselves.

Heard-Garris said.

“Children don’t vote, and so their voices aren’t often heard,” Heard-Garris said. “They are a

“There are structures that have contributed to the disenfranchisement of people, and that’s what’s different. We’re not measuring race.

We’re measuring racism and oppression.”

natural population to try to be advocates for, and they’re our next generation and leaders.

If no one’s going to fight for them, what’s our future going to look like?”

Heard-Garris still remembers the time in medical school, when she met with legislators in D.C. and spoke about the importance of removing junk foods from vending machines to create healthier options for kids.

Heard-Garris,

an

Assistant

Professor

of

Pediatrics at the Feinberg School of Medicine,

“I remember them saying, ‘Well, kids should

dedicates her time to studying how racism,

have

discrimination, and other adverse events

decisions,’” Heard-Garris said. “I was like, ‘Can

experienced in childhood affect health

we even make good decisions?’ When I heard

outcomes later in life. She defines herself

that, I knew that we had a lot of work to do.”

more

willpower

to

make

better

as a health equity scholar and seeks to push discussions beyond just the recognition of

Heard-Garris spent a lot of her time on Capitol

inequity.

Hill as a medical student, resident, and Robert Wood Johnson Clinical Scholar, in which

“When we limit it to disparities, we’re just

she served as a fellow at the United States

talking about differences, but health equity

Department of Health and Human Services

scholars challenge that and say it’s not the

and supported the response to the Flint

disparities,” Heard-Garris said. “The differences

Water Crisis and the Zika virus. She wanted

are symptomatic of a much larger problem

to pursue a career in government where she

with racial equity, social justice, and structural

could work directly with senate leadership to

racism.”

craft policy and drive health equity forward.

But during her time as a fellow, she realized

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Discussions of health equity often focus on

that more research was needed to inform and

disparities in chronic disease management

drive policy change. It was the data that made

Shi policies robust.

type two diabetes, and you tell them to go get this medicine, but there’s no pharmacy in their

“Government leaders need evidence and

neighborhood, and you tell them to go play

evidence-based

outside, but there’s gunshots and there’s no

solutions,

research,

and

strategies that speak to what they are trying

Allysa Benedict Artist

green space—of course it’s tied to health.”

to decide on,” Heard-Garris said. “I realized I could be just as effective and maybe even a

Driving structural change and advancing

little more effective outside of government,

health equity thus requires a multi-sector

providing government leaders and legislators

approach. It involves redesigning curriculum,

with data, science, and research to help them

recruiting and retaining more diverse students

on issues that are very complex.”

and leaders, funding the research, becoming an anchor institution, and investing in local

In the past, people have told her to “stay in

infrastructure. It involves bringing together

[her] lane,” Heard-Garris said, and focus on

clinicians, local organizations, legislators, and

practicing pediatrics. But medicine and health

community members and leveraging the full

extend beyond the hospital walls and require

force of multidisciplinary partnerships.3

not only biomedical advancement but also social innovation.

“There are multiple layers [of adversity], and that’s why it’s important that doctors and

It has been shown again and again that investments in policies addressing poverty, hunger, education, insurance, and other social determinants have directly improved birth outcomes, overall health outcomes, and overall healthcare access.4

medical professionals don’t try to do this on their own because there’s no way you can tackle structural racism with a one-size-fitsall approach,” Heard-Garris said. “You need partners in school systems, social services, foster care, government.”

Allysa Benedict graduated with a BFA in Art and Design at the University of Michigan where she specialized in illustration.

She completed a Masters of Science in Biomedical Visualization at the University of Illinois at Chicago where she took classes in molecular visualization, 3D modeling, anatomy, animation, and illustration. Allysa focuses on creating captivating and educational visuals for a variety of audiences. She is currently a Media Artist and Medical Illustrator for the company TrialGraphix.

There is a lot of work to be done. But that also means there are many ways to get involved.

“At every level, especially in medicine, whether you’re an undergraduate student or graduate

“As a pediatrician, I’m with patients for 15 to

student or resident, you have some level of

20 minutes—it’s a blip in their day, let alone

power and you have some level of access,”

their lives,” Heard-Garris said. “Where they go

Heard-Garris said. “How will you choose to

back to live, work, and play is extraordinarily

make the medical environment a place for

important. When you diagnose your kid with

everyone?”

1. Sanders-Phillips K, Settles-Reaves B, Walker D, Brownlow J. Social inequality and racial discrimination: risk factors for health disparities in children of color. Pediatrics. 2009;124 Suppl 3:S176-S186.

3. Jindal M, Heard-Garris N, Empey A, Perrin EC, Zuckerman KE, Johnson TJ. Getting “Our House” in Order: Re-Building Academic Pediatrics by Dismantling the Anti-Black Racist Foundation. Acad Pediatr. 2020;20(8):1044-1050.

2. Cave L, Cooper MN, Zubrick SR, Shepherd CCJ. Racial discrimination and child and adolescent health in longitudinal studies: A systematic review [published online ahead of print, 2020 Feb 27]. Soc Sci Med. 2020;250:112864.

4. Trent M, Dooley DG, Dougé J. The Impact of Racism on Child and Adolescent Health. Pediatrics. 2019;144(2):e20191765.

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Malcolm Houston Artist

Malcolm Houston is from Richmond, Virginia, where he graduated from Virginia Commonwealth University with a Bachelor of Fine Arts in communication arts, with a concentration in scientific and pre-medical illustration and minor in biology. From an early age, he had a natural affinity for biology, visual arts, and sports. He started his educational career as a physical therapy major, but quickly transitioned to the field of medical illustration when he realized a preparatory path was being offered at his undergraduate university. Using art to explain scientific concepts was more aligned to his natural strengths, and further education was the only way to delve deeper into the medical illustration process. After completing his undergraduate degree, he went to obtain a Master of Science in Biomedical Visualization at the University of Illinois at Chicago. Malcolm currently works as a medical illustrator, creating content to help both accurately and aesthetically depict scientific information for educational purposes.

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RECEIPT OF THE ANNUAL INFLUENZA VACCINE is a longstanding racial health disparity that often receives less attention. The limited supply of the COVID-19 vaccine in early 2021 drew global attention to distribution inequities. Dr. Grace Bellinger, Co-Editorin-Chief of NPHR, met with Dr. Muriel Jean-Jacques, an internal medicine physician who serves as co-chair for the Northwestern Memorial HealthCare Quality and Equity Committee, in February 2021 to discuss disparities relevant to the flu vaccine. At the time of this interview, rollout of the COVID-19 vaccine was in its very early stages and there was broad discussion surrounding how to make the process more equitable.

On Vaccine Hesitancy An Interview with Dr. Muriel Jean-Jacques Grace Bellinger, PhD, MPH

(MJ):

lower than that of White patients. We also

Tell me more about the racial disparities

There are longstanding and persistent

see persistent ethnic disparities between

surrounding receipt of the flu vaccine.

disparities in receipt of the flu vaccine,

patients that identify as Hispanic and Non-

with rates being lower for racial and ethnic

Hispanic, but the differences are lower in

minorities compared to White patients.

magnitude. These racial disparities have

We see consistent disparities in receipt of

been shown nationally, state-wide, city-

the flu vaccine across all regions in which

wide, and within our own healthcare

Northwestern Medicine delivers care, with

system.

DR.

GRACE

BELLINGER

(GB):

DR.

MURIEL

JEAN-JACQUES

the rate among Black patients being 5-15% 16

GB: Why do these specific racial disparities exist?

when interacting with patients who are hesitant to receive the flu vaccine. How do you approach patients

MJ: Some major factors are trust in the healthcare

with humility?

system (or lack thereof ), trust in the pharmaceutical industry and safety, and trust in the recommendation

MJ: I start by asking people what their concerns

of the physician or healthcare provider in front of the

are about the flu vaccine. Is it based on personal

patient. Scientific understanding and acceptance also

experience, or the experience of a loved one, or

contribute to disparities in vaccine receipt.

someone they know? Where I think we go awry in healthcare is when someone tells us something and

GB: How can these disparities be addressed?

we say, “No, that didn’t happen.” You are not going to get anywhere with that. If they say, “I had the flu shot

MJ: Patient education, general health education,

and it made me sick” and you respond with, “No, the

and the use of ambassadors can help address the

flu shot does not make you sick,” what are you telling

persistent disparities. Ambassadors are trusted people

them? That they are lying, that they did not get sick,

from within a particular community, such as religious

that they do not know how to tell what is happening

leaders, physicians, teachers, or leaders of community

to their body? You can instead start with, “Can you tell

organizations. Leaders within a community act as

me a little more about that, did it start right after your

ambassadors by sharing messages about the efficacy

shot?”

and safety of vaccines. It is very important to try to change how people think about vaccines before they

As a healthcare professional, you do not want to

walk in the clinic door. If someone declines a vaccine

presume. If the symptoms started a couple days after

in the clinic, it can be harder to move the needle. Yes, it

the vaccination, that could be the patient’s immune

is still possible to have a conversation about vaccines,

system responding to the vaccine. But if it happened

but if you start with a no rather than ambivalence, it is

weeks later, or if the patient was diagnosed with the

more difficult.

flu, we can discuss the flu versus all the other seasonal bugs that can make someone sick. If you do not

The team members at the clinic also matter. In our

understand where a patient is coming from in rejecting

practice, we have a model in which the medical

a vaccine, it is going to be hard to have a productive

assistants or nurses initiate the discussion about

conversation. Just saying, “No, you are wrong,” is not

receiving the flu vaccine as they room the patient. The

going to get you anywhere, in my experience.

team members’ acceptance of vaccinations, as well as their racial or class concordance with the patients, can

GB: You recently wrote an editorial published in JAMA

influence receipt.

about COVID-19 vaccination programs. In the weeks since that article was published, do you think vaccine

When we talk about trust in the healthcare system,

distribution efforts have been equitable?

we often focus on individual patients not trusting us.

This places the problem on the patient’s lack of trust,

MJ: I think there have been efforts to make it equitable,

as if they are the one who needs to be intervened

but they have been very hampered by the overall

upon. We also need to spend more time and effort

limited supply of the vaccine relative to the very

discussing the ways in which the healthcare system

high demand. I feel that people trying to implement

has previously done and continues to do things that

equitable programs have been burned and criticized

are untrustworthy. The more that we can recognize,

from both ends. If you are getting burned or criticized

address, and own up to that, correct and acknowledge

from both ends, you are probably doing something

prior wrongs, and undo current injustices from within

right.

the healthcare system, the better off we will be. The healthcare system needs to sustain that over time and

For example, I have seen criticisms that trying to

show themselves to be trustworthy.

account for equity makes the system too complicated.

It is much easier to say that we are going to vaccinate

GB: In a recent media campaign by Northwestern

all people 65 and older. It is harder to put into action

Medicine, you mentioned that you start with humility

[a program] that is going to vaccinate people older 17

Bellinger

On Vaccine Hesitancy than 65 and people who are at the highest risk based on their

GB: Do you have any final thoughts to share on this topic?

race, zip code, or occupation. There are criticisms that those considerations are going to make the rollout too slow. At the same

MJ: There has been a lot of messaging around patients learning

time, programs that have tried to target certain neighborhoods or

about and receiving the vaccine from a trusted source. Trusted

high-risk occupations have also received criticism when they have

sources do not all have to be Black and Brown, and I think that is

not strictly enforced rollout in those communities. They have not

important to mention. Many students here at Feinberg, whether

asked for a work ID or proof of residency, and therefore people who

they are racially, ethnically, or culturally congruent or not with

do not meet those criteria have come in to get the shots that were

patients, have been able to change many people who are hesitant

reserved for others.

from a “no” to a “yes.” They are using their skill sets and instincts to meet people where they are, actively listen, address concerns, and

Those are some of the challenges. Yes, it may take more time to

talk through the facts. It is not either being a trusted source or using

do things equitably and try to get the vaccine to those who are

these skills. It is both. Trusted ambassadors may be more effective,

at highest risk first. At the same time, trying to be human about it

but individuals not from the community can also be effective

and not act like police in terms of strict enforcement also invites

advocates and allies to move the needle on vaccine receipt equity.

people to game the system. People leading these programs have been thoughtful. They realize there is the opportunity for gaming the system and hope people will not do it because the ultimate goal is to vaccinate those who need it.

Again, if you are getting criticized on both ends, you are probably doing something right and working in an area that is challenging.

Some cities or counties are doing both strategies. There is [a portion of ] vaccines allotted in first-come-first-serve style that requires high-speed Internet access and the time to constantly hit refresh. Then there is a portion held for certain people in the community who really need it. That is a great strategy but is difficult

MURIEL JEAN-JACQUES, MD is an Assistant

to implement when there is a limited supply and people feel like

Professor in the Division of General Internal

they are not getting what they need fast enough.

Medicine and Geriatrics at the Northwestern University Feinberg School of Medicine. Her

The thing that’s been interesting to me as far as the COVID vaccine and vaccine hesitancy is that it truly has been hesitancy rather than denial or refusal.

research focuses on the implementation and dissemination of quality improvement initiatives that aim to eliminate disparities in healthcare quality in primary care settings. Her educational focus is on issues related to social determinants of health, health equity, and health advocacy.

She maintains a busy outpatient primary care practice with a focus on serving those who

18

Hesitancy can be overcome but it takes time. The reason I like

face significant medical and/or psychosocial

the dual approach just described for distribution is that it allows

challenges. She serves as Associate Vice Chair

you to have some time to put in the work to build the trust,

for Diversity Equity and Inclusion for the

address concerns, get from hesitancy to “yes,” and then be able to

Department of Medicine and as Co-Chair of

convert that “yes” into receipt of the vaccine. People have been

the Quality Equity Committee for Northwestern

understanding because the short supply has been well-publicized,

Medicine and in these roles has developed

but it is still very frustrating for those doing the work on the ground

and led initiatives to advance health equity for

if they cannot finish the task due to lack of supply.

patients and communities served by NM.

19

“Of all the forms of inequity, injustice in healthcare is the most shocking and inhumane.”

- Martin Luther King Jr.

Expanding Equitable Access to Organ Transplantation Dinee Simpson, MD

One of the leading causes of death

health and function. Once the kidney fails,

Simpson was first exposed to the realities of

in the U.S. is kidney disease.1,2 Kidney

the only remaining options for patients are

racial disparities in kidney disease treatment

disease

at

receiving dialysis or a kidney transplant. When

during her time as a resident physician at the

a rate nearly four times higher than their White

affects

Black

Americans

fighting kidney disease, the greatest success

Brigham and Women’s Hospital of Harvard

counterparts. In fact, despite comprising only

occurs when patients in the early stages

Medical School. It was during this training

13% of the population, Black individuals

receive specialty care through a nephrologist,

that she was able to engage firsthand with

account for 35% of all dialysis patients.

a kidney specialist.

the transplant process and noticed not only

2

Despite this health inequity, Black patients are less likely than White patients to be referred to transplant, less likely to be listed for transplant, and experience longer wait times once listed.

Dr. Dinee Simpson, Northwestern University’s first Black transplant surgeon and the first

the “overwhelming burden of kidney disease

However, nearly 40% of patients diagnosed with kidney disease never receive specialist care.

Black female transplant surgeon in the state

in the Black community,” but also how the potential for bias seeps its way into the organ transplant selection process.

In the first step of the kidney transplant timeline, the patient goes to see their primary

of Illinois, sought to address these inequities

This can be linked in part to structural and

care physician. If indicated, the patient will

by founding the African American Transplant

institutional racism, ultimately contributing

undergo certain blood and/or urine labs to

Access Program (AATAP), an organization that

to worse health outcomes among minorities.

assess kidney function. If the results suggest

works to assist Black patients in navigating the

Black Americans have higher rates of

significant kidney dysfunction, the patient is

transplant process.

comorbidities, including diabetes and high

often then referred to a nephrologist for more

blood pressure, which are the leading causes

specialized care. If medical management is not

Currently, early detection of kidney disease

of kidney disease. Additionally, Black patients

sufficient and kidney transplant is indicated,

is the foremost tool in mitigating long-term

progress to end-stage more rapidly than White

the patient will then be referred to a transplant

effects, as early detection can allow patients

patients, are less likely to be treated via kidney

team for evaluation. If determined to be an

the opportunity to make any lifestyle changes

transplant, and spend a greater length of time

appropriate candidate for transplant by the

that are necessary to support their kidney

waiting for an organ than White patients.

transplant committee, the patient is placed

20

on a national organ recipient waitlist. Priority

Neighborhoods in places like Chicago tend

Regan Falin

is determined based on many objective and

to be unofficially segregated by race and

Artist

subjective factors, including severity of kidney

income due to a history of racist redlining

function, medical comorbidities, and social

practices. The minority communities within

circumstances (such as ability to manage the

these cities tend to have higher air pollution

post-transplant care).

and less access to healthy foods, green spaces, and health resources. Given that transplant

“[A] lot of the structural barriers that minority

centers and specialists are often located

patients tend to face—because they tend to

outside these minority communities, patients

be of lower socioeconomic status, have less

face additional barriers that may cause

education, and live in impoverished areas

them to drop off of the transplant pipeline,

[with] less access to good health resources—

including not having sufficient transportation

can create stereotypes and biases for how fit a

or childcare available to attend appointments.

patient is to take care of a transplanted organ

AATAP is designed to be an intermediary and

and therefore puts them at risk for not being

provide identified individuals with additional

selected,” Simpson said.

support in navigating those barriers “so that they can get to the transplant evaluation

These observations spurred Dr. Simpson into

process and experience it as equally as anyone

establishing the African American Transplant

else,” Simpson said. The AATAP team maintains

Access Program (AATAP) within Northwestern

a social worker on staff that can assist patients

Medicine to serve the Chicagoland area. The

with overcoming the more psychosocial

program is anchored around four pillars—

factors that can sometimes complicate health

trust, cultural competency, health literacy and

attainment.

diet, and psychosocial support—that enable it to fulfill its two primary goals:

1 2

It is well-documented that Black Americans have a history of distrust in the medical

Improve access to resources that help African American patients navigate the transplant process and achieve better health through transplantation; and

community due to the harm healthcare

Continue to be a trusted destination for transplantation among African American patients and improve trust in healthcare overall.

are retold and shared amongst community

providers have inflicted on Black individuals over centuries. If an individual has a poor experience in a doctor’s office, they are likely to share the narrative of that experience with friends and loved ones out of genuine concern or a desire to protect others from having a similar experience. These stories

Regan Falin was raised in Cleveland, Ohio and has wanted to pursue Biomedical Visualization since her junior year of high school, after her art teacher introduced her to the field. With this goal in mind, Falin went to Ohio University, majoring in Studio Art: Painting and Drawing and minoring in Biological Sciences, to curate the artistic skills and scientific knowledge required for medical illustration. After graduating in 2019, Falin immediately started graduate school at the University of Illinois at Chicago (UIC) to get her Master of Science in Biomedical Visualization. At UIC, Regan dabbled in 3D modeling, interactivity, and animation, and her love for illustration only grew. Today, Regan is working as a Medical Illustrator at Amicus Visual Solutions in Richmond, VA.

members and can ultimately contribute to distrust. This distrust is the footstool for many Black patients not viewing transplantation as a viable or accessible treatment option for kidney disease.

To reach across the chasm of medical

A patient’s environment, defined here as the

distrust, members of the AATAP ensure race

resources available to the individual within

concordance between the provider and the

their immediate community, plays a large role

patient in the initial evaluation visit, helping

in a patient’s access to health resources. The

to remove some feelings of otherness that

zip code within which one lives, particularly

literature demonstrates might arise when

in large metropolitan areas like Chicago,

the medical provider and patient are not of

can influence life expectancy by up to 30

a similar racial background. The team also

years depending on the neighborhood.

practices patient-centered communication,

3

21

Expanding Equitable Access to Organ Transplantation

Smith

focusing on establishing a relationship

provide full assistance to those who need it

between the medical provider and the patient

the most.

by not allowing time to be a constraining factor. During a patient’s initial visit with the AATAP team, patients and providers spend a considerable amount of time getting to know each other so that the patient can feel like AATAP team members are truly their champions.

In addition to these meaningful engagements, the AATAP is working with community leaders

In the program’s first year, Northwestern Medicine saw a 55% increase in the number of Black patients evaluated for transplant and an 18% increase in the number of Black patients listed on the transplant waiting list.

in minority neighborhoods to bring awareness to both the AATAP program and kidney disease.

The goal in creating programs like the

Through public service events and community

AATAP and the Hispanic Transplant Program,

engagement, AATAP aims to increase health

created by transplant surgeon Juan Caicedo-

literacy so that Black Americans may feel more

Ramirez, is not to segregate the transplant

comfortable navigating information about

process into the “Black Transplant Program”

their personal healthcare.

and the “White Transplant Program.” Rather, the goal is to assist patients in overcoming

At present, patient participation in AATAP

barriers and provide them equal opportunity

is referral-based, which allows the team to

to engage in the transplant process.

DINEE SIMPSON, MD is Northwestern Medicine’s first Chief Health Equity Executive. As Associate Professor of Surgery in the Division of Organ Transplantation, she is the first and only Black woman transplant surgeon in Illinois and one of only 11 in the United States. She founded the African American Transplant Access Program in 2019.

1. Centers for Disease Control and Prevention. Kidney Disease.

Published September 20, 2022. Accessed September 11, 2024. https:// www.cdc.gov/nchs/fastats/kidney-disease.htm 2. National Kidney Foundation. Kidney Disease Fact Sheet. Published February 2023. Accessed September 11, 2024. https://www.kidney. org/about/kidney-disease-fact-sheet

22

3. Gibson M. Why Your Zip Code May Be the Most Important Predictor of Your Health. Time. Published April 24, 2019. Accessed September 11, 2024. https://time.com/5608268/zip-code-health/

Mikaela Muersch Artist

Mikaela Muersch is a medical illustrator from the south suburbs of Chicago. She received her Master of Science in Biomedical Visualization from the University of Illinois (UIC) at Chicago. She discovered this unique field during her undergraduate studies and was excited that she could use art to help educate people to live happier, healthier lives. With a background in figure drawing, Muersch has keen observational skills and expertise in anatomical accuracy. After receiving a Bachelor of Fine Arts in Life Drawing from the American Academy of Art, she continued developing these competencies during her time at UIC, in addition to taking various courses in the biological sciences. Muersch aims to use her creativity and visual problem-solving skills to make useful and meaningful visualizations that fill a communication gap. More of her work can be seen on her website MikaelaRianne.com.

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Nicole Shepherd Artist Nicole Shepherd grew up in the Chicago suburbs and attended the American Academy of Art downtown where she graduated as valedictorian with a BFA in Illustration. As an undergraduate student, Nicole worked primarily with traditional media or digital illustration, but her skills and interests have expanded throughout her time in graduate school. She has gained a passion for 3D modeling and interactive development and seeks out a career in the emerging field of interactive media and virtual reality. She considers herself a lifelong learner and feels fortunate that she has found a field that caters to this pursuit of knowledge.

She is currently completing her Master of Science in Biomedical Visualization at the University of Illinois at Chicago.

Northwestern Features

1

CHET

The Center for Health Equity Transformation (CHET) works to expose racism and other root causes of health inequities through research, education, and community engagement.

CHET is a joint center between the Robert H. Lurie Comprehensive Cancer Center and the Northwestern University Institute for Public Health and Medicine (IPHAM). Dr. Melissa Simon founded CHET with her diverse health equity and community-based participatory research,

teaching,

and

community

partnership portfolio spanning more than a decade.

CHET’s research projects address many racial disparities, especially in maternal health. Black and Latinx individuals have the highest risk of maternal mortality and severe maternal morbidity compared to any other group in the U.S. The OPTIMIZE research study, funded 25

Bellinger

Northwestern Features by the National Institute on Minority Health

CHET has also forged connections with

equitable opportunities to underrepresented

and Health Disparities, is implementing a

the community to address cancer health

minorities.

comprehensive perinatal care checklist to

disparities

the

T37 Minority Health and Health Disparities

assess ways to increase access to care and

Chicago Cancer Health Equity Collaborative

Research Training Program (NU-MHRT), Health

support before, during, and after pregnancy.

(ChicagoCHEC).

The Well-Mama Doula Project also aims to

the

through

projects

like

The

Northwestern

University

ChicagoCHEC

is

Equity Scholars Program, and Career 911: Your

comprehensive,

tri-

Future Job in Medicine Massive Open Online

increase support for Black, Indigenous, and

institutional partnership to advance cancer

Course (MOOC) all offer unique research,

People of Color (BIPOC) persons through

health equity in the city of Chicago. Since its

educational, and mentorship opportunities to

community doula navigators.

inception in 2015, ChicagoCHEC has funded 9

undergraduate students and beyond.

Midwest’s

first

grants for 32 investigators, been a part of 195 Community media outreach takes many

peer-reviewed publications, and developed

forms at CHET. The center’s newsletter Voices

two smartphone applications (in English and

provides up-to-date information on local and

Spanish) for breast cancer survivors and cancer

national initiatives, highlighting health equity

survivors with disabilities. The goal of one of

research, resources, funding opportunities,

the current ChicagoCHEC research projects is

and events. The center’s podcast Skinny

to address the four- to five-fold increased risk

Trees: Lift Health for All seeks to provide

of death from hormone-dependent breast

insight on health equity from researchers and

cancer that Black women in Chicago face

the community. The goal of the podcast is to

compared to White women.

discuss the importance of achieving health equity, highlighting health disparities, and

In addition to research and community

exploring innovative ways to improve health

partnerships, CHET offers a variety of

for all.

educational and training programs to provide

2

STRIVE

CHET is dedicated to equipping the next generation with the skills and experience to advance health equity, diversify the workforce, and improve health outcomes for all.

The road to a career in medicine can be

show students firsthand how to tackle and

particularly arduous for medical students

overcome certain barriers in medical school.

who are underrepresented in medicine (UIM). Learning the ins and outs of anatomy and physiology is challenging but doing so in an environment that can, at times, be unwelcoming

due

to

microaggressions,

bias, and overt racism can seem downright impossible. What structures are in place to support students as they go through the process? Can mentorship help?

Students also have the opportunity to see someone who looks like them in a position they may want to be in in the future.

The Student to Resident Institutional Vehicle

26

for Excellence (STRIVE) was founded to answer

This can serve as inspiration for career

these questions. STRIVE is a peer mentorship

development and specialty choice, especially

program that supports UIM medical students

in fields that have less representation. In such

at Feinberg through panel discussions,

a way, STRIVE and other similar programs can

curriculum review sessions, and social events.

improve the medical training experience for

Residents and fellows who are UIM and

those who may otherwise feel marginalized

have encountered similar obstacles serve

and constrained by their racial, ethnic, or other

as mentors for students. They can therefore

UIM identity.

3

Nicole Hampshire Artist

PPH

Northwestern University’s Program in Public

He

Health (PPH) offered an elective on Structural

syllabus reflected upon the role of slavery in

wanted

Racism and Race Disparities in Health for the

shaping Black American history, while also

first time in the spring of 2021. PPH faculty and

recognizing that other minority groups have

administrators suggested the course in

faced similar challenges within the healthcare

alignment with efforts to create a more inclusive

system.

learning environment. The course was taught

social constructions of health through an

by Dr. Omari W. Keeles from the Department

interdisciplinary lens and examined key

of Preventive Medicine, who was given

theoretical frameworks and foundational

full autonomy to design the course structure

public health data. Students evaluated how the

and requirements. There was overwhelming

U.S. healthcare system can put the health and

interest in the course, with several students

well-being of racial and ethnic minority groups

being waitlisted or opting to audit the course.

and other vulnerable populations at risk and

The

to

ensure

course

that

content

the

explored

identified opportunities for intervention and Keeles

aimed

to

design

an

engaging

change.

graduate-level course that was interactive, individualized, and collaborative. His primary

Keeles

intention was for students to critically assess

inspire additional courses focused on the

hopes

how societal structures have been purposely

health

stratified to privilege certain groups and

communities. Since clinicians and public

disenfranchise, marginalize, and oppress other

health

groups. Keeles sought to foster a community

communities, it is important that graduates

of learners in which every individual—the

of the Master of Public Health program have

students, professor, and two graduate student

a nuanced understanding of the ways in

instructors—was contributing to knowledge

which a person’s intersectional social identities

creation. He hoped students would finish the

impact their health outcomes and experiences

class with an impactful and lasting experience

with the healthcare system. Ultimately, Keeles

after being challenged in ways related to their

envisions the foundational aspects of this

growth and learning.

course eventually being integrated into the

and

this

well-being

practitioners

course of

work

will

marginalized in

various

Nicole Hampshire graduated from the University of Illinois at Chicago (UIC) with a Master of Science degree in Biomedical Visualization in 2021. She now works as an Associate Medical Illustrator at Osso VR, a cutting edge surgical simulation company. During her time at UIC, Hampshire was elected Social Chair of UIC’s Student Association of Medical Artists and joined the Association of Medical Illustrators as a student member. Outside of her professional work, Nicole enjoys training for and competing in athletic competitions, cooking, and working as a personal trainer at a local gym.

core public health curriculum so that an

In selecting content, Keeles was intentional about extending beyond a binary Black-White paradigm of race.

elective course dedicated to structural racism is no longer necessary.

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About NPHR The Northwestern Public Health Review is a student-

PARTNERSHIP WITH BVIS

run organization founded in 2013 to share and stimulate

Founded in 1921 by Thomas Smith Jones,

multi-disciplinary conversations about current public

the Biomedical Visualization (BVIS) graduate

health issues. Through our print issues, blog, and campus

program at the University of Illinois at Chicago

events, we hope to help the Northwestern and broader

is one of only four accredited graduate programs

Chicago community achieve greater health equity.

in North America that provides professional training for careers in the visual communication of life science, medicine, and healthcare. The program’s curriculum provides a foundation in medical science, learning theory, and innovative visualization techniques, with the opportunity to explore new fields in animation, interactive

media,

educational

gaming,

stereography, haptics, and augmented reality.

This journal issue is the eighth time that BVIS students have contributed editorial illustrations to the Northwestern Public Health Review.

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Grace Bellinger, PhD, MPH Co-Editor-in-Chief Joo-Young Lee, MD Co-Editor-in-Chief Meilynn Shi Co-Editor-in-Chief Jerome Wang Design Editor Ciarra Smith Staff Writer Sapna Suresh, PhD Staff Writer Rachel O’Sullivan, JD Staff Writer

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Northwestern Public Health Review Fall 2024 Issue