Vulnerable populations at home and abroad

“If you want to advance health equity, there is as much to do within 10 blocks of here as there is within 10,000 miles,” Mary T. Bassett, M.D., M.P.H., told a packed house in Fitkin Amphitheatre during the grand rounds lecture that kicked off the Department of Medicine’s Sixth Annual Global Health Day in March.

Bassett drew upon a wealth of experience, both personal and professional, in her talk “From Harlem to Harare: Health Equity in Global and Local Perspective.” Health equity, she said, is linked to socioeconomic inequity, and racism. In a talk later that day, she described childhood visits to Virginia, where her black father and white mother could not be seen together since interracial marriage was illegal in that state. As a Harvard undergraduate she volunteered at a free clinic started by the Black Panther Party, where she met Gerald Friedland, M.D., then a resident and fellow at Boston’s Beth Israel Hospital, and now professor of medicine (epidemiology) and of epidemiology (microbial diseases) at Yale. After obtaining her medical degree from the Columbia University College of Physicians and Surgeons in 1979, where she was the only black woman in her class, she went to Harlem Hospital for her residency. There she came to the realization that the health of her patients depended on factors outside the clinical setting, prompting her to pursue a master’s in public health from the University of Washington. She then spent 17 years in Zimbabwe on the medical faculty of the University of Zimbabwe, developing interventions to prevent and treat HIV during the height of the AIDS epidemic. Today, she is commissioner of the New York City Department of Health and Mental Hygiene.

Internationally, she linked the demise of primary health care to the global debt crisis and “structural adjustment” policies in sub-Saharan Africa that led to massive cuts in health and education services. She noted that there has been a departure from the 1978 Declaration of Alma-Ata, which defined health as a socioeconomic issue and a human right. Health inequities, she said, are a form of injustice and violence that are tied to issues of race and inequality.

Bassett believes that public health concerns need to be addressed by both “bottom up” and “top down” strategies. In New York City, she adopted Zimbabwe’s community engagement strategy, identifying neighborhoods with the highest disease burden and creating Neighborhood Health Action Centers. These “hubs for health” combine clinical services and community organizations in one space. Noting that diabetes has been poorly controlled in New York City during the last decade, she identified five public housing hotspots and assigned community health workers to educate and engage patients. She has also lead such policy initiatives as banning smoking and trans fats in restaurants and introducing a sodium warning icon in chain restaurants.

Although there has been progress in such health indicators as infant mortality, there has been a widening gap in socioeconomic and racial and ethnic inequities since 1981. Bassett believes this context is important. The crisis of lead in drinking water in Flint, Mich., she said, stems from racism and socioeconomic status—an independent panel found that disregard for the concerns of poor and minority people contributed to the government’s slow response.

When asked about institutional racism today, she noted that only 35 percent of New York City’s population is white, yet when she took over as health commissioner in 2014 there were no African Americans on her senior leadership team. She said she has brought the issue of racial inequity to the attention of the deans of medical schools in New York City. She is leading by example but said that everyone needs to do their part, concluding “I promise we will see our way to a healthier and more just world.”

Later that afternoon, Bassett continued the conversation in a moderated discussion with Friedland and Tracy Rabin, M.D., assistant professor of medicine. Three residents at Yale-New Haven Hospital, Ani Annamalai, M.D., Amir Mohareb, M.D., and Kevin Ikuta, M.D., presented their perspectives on “Providing Care to Refugees: The New Haven Experience.” About 560 refugees settle in Connecticut each year, the residents said, mostly in New Haven, Bridgeport, and Hartford, cities with resettlement agencies. The Yale Refugee Clinic, which opened in 2007, screens between 200 and 300 patients per year. And the disease burden of refugees can vary from country to country, but can include post-traumatic stress disorder, malnutrition, sexual- and gender-based violence, and female genital mutilations.