East 96th Street in Manhattan is an extraordinary dividing line. The health of people living north of that cross street has dramatically differed from those living south. It was enough of a difference to make one Puerto Rican boy growing up nearby take notice.
"I had a bird's-eye view of the health disparities that exist between the Upper East Side, one of the communities with the highest concentration of millionaires, and those of us living on the other side in East Harlem," said Adam Aponte, MD. He grew up on East 97th Street and went to medical school across the avenue at Mount Sinai, becoming a pediatrician and, eventually, the youngest department chair at North General Hospital. "The striking differences between those communities in terms of crime, drugs, schools, hospitals and health conditions really struck me, and I wanted to do something about it. I thought, why are these two communities so disparate while they're literally only 100 feet apart?"
Aponte, CEO and Chief Medical Officer of the East Harlem Council for Human Services, Inc., is committed to answering that question and minimizing and ultimately eradicating health and healthcare access disparities. He offers six ways we can begin.
1. Establish Trust
Gaining the trust of patients and families is imperative to ensure they take medications as prescribed and adhere to recommended healthcare regimens. Respecting culture is a critical component of this effort.
"Culture is the lens by which we see the world," Aponte asserted. He recalled how his mother would apply Vicks VapoRub® on his chest when he was sick, even though it was primarily palliative. If a doctor told her to stop doing that and gave her a prescription instead, she might have tossed it in the trash. "She might curse him out because he was so disrespectful to her and her culture," Aponte added.
He recommended focusing on building relationships and forging bonds. "Not all home remedies are harmful, and you have to have respect and appreciation for them," he explained. "The doctor could have said, 'That's great, and there's no harm, but Adam really needs these antibiotics as well.' It's all about nurturing those relationships."
2. Fortify Navigation Services
Patients who need more than one provider for their healthcare can get lost along the way, especially if they have a complex condition. Social influences such as food insecurity, language barriers, poor housing conditions and transportation obstacles can impair their ability to get the care they need. "Every patient should have a care manager, someone who helps them navigate their way through this complicated healthcare system of ours," emphasized Aponte.
At the Boriken Neighborhood Health Center that he leads, patients have access to pediatric and adult primary care, prenatal care, behavioral health services, nutritional guidance and a pharmacy, as well as coordination of the services they need by a care manager — all in one centralized location. Those who need care beyond the center are referred to local hospitals such as Mount Sinai Hospital, Harlem Hospital and Lenox Hill Hospital.
3. Enhance Resources
As a Federally Qualified Health Center (FQHC), the Boriken Neighborhood Health Center receives government funding to provide its services. But its revenue is limited by resources and reimbursement rates. FQHCs like Boriken are especially challenged by the influx of immigrant patients to New York City who need healthcare services.
Aponte argued that with increased funding, he and his team could more effectively keep patients out of the emergency room, reduce the chance that they need to be admitted to the hospital, ensure they adhere to their medications and see all the specialists they need.
"If they give me the funding to do that, I'll decrease the total cost of care. That will also save money for insurance companies," he explained. "Then, what I want them to do is to share those savings with me. That's called 'value-based contracting.' It's nothing new. We need to be in that business, and FQHCs have a hard time getting into that business because of the way that we are structured."
4. Diversify Research
Clinical trials have traditionally been plagued by a lack of diversity among the enrolled patients. Hepatitis C treatments, for example, were primarily successful for white individuals because those were the patients in clinical trials. Black people with hepatitis C in East Harlem who were treated with the same drugs experienced adverse effects, "so much so that they stopped using those medications in our community," said Aponte. "When we talk about diversity and equity, it's about not treating everyone the same." While there needs to be more equity in healthcare access, there should be more diversity in clinical trial enrollment.
5. Improve Health Literacy
Health literacy isn't necessarily about educational attainment. It's about understanding one's health and the instructions that healthcare providers give. Aponte recommends the "teach-back" method, where patients are asked to repeat the instructions they receive from their healthcare professionals.
"We make sure we speak in simplified terms and avoid acronyms and abbreviations," he explained. "We try to keep it at a level where patients can really understand what we're trying to say. Health literacy has the greatest impact across the board."
6. Inspire Youth
One of the best ways to reduce health inequities is to encourage youth from underserved communities to aspire to STEM careers. The nonprofit organization Mentoring in Medicine, whose board Aponte chairs, connects nonwhite students with opportunities that help them get into healthcare professions. Some 500 students have been accepted to medical schools, thanks to the organization's programs.
"We inspire kids by telling them to dream big is free and show them that they can do this work," he concluded. "I was a smart student, but more importantly, I was dedicated and passionate. I had a dream and a focus. When you put all those things together and you make sacrifices, your dreams can come true."