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Improving Health Equity in Clinical Care and Research

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Brigham and Women’s Hospital has a long and rich history of providing complex clinical care with a focus on health equity, diversity and inclusion. The Brigham has continued to build on its legacy by establishing clinical programs, engaging with diverse communities and conducting research that addresses health disparities, social determinants of health and structural racism in clinical settings and beyond.

Four decades ago, the Brigham established the Southern Jamaica Plain Health Center (SJPHC) and the Brookside Community Health Center to provide accessible care to Boston’s underserved communities. Wanda McClain, MPA, vice president of the Center for Community Health and Health Equity (CCHHE) at the Brigham, believes that these community health centers are the Brigham’s most significant vehicle to ensure diverse and equitable access to clinical care in the community. “At the Brigham, health equity means ensuring that every person has access to the best possible health outcomes,” said McClain.

Diverse and Equitable Health Care at the Brigham

To improve inequities in maternal and infant health outcomes among Black and Latinx women and their infants, the Stronger Generations program at the CCHHE has made a number of changes to improve access to prenatal care visits for these patients. The changes come on the heels of research that showed that Black women are at increased risk of serious health complications after giving birth. Moreover, infants born to a Black mother in Boston are nearly five times more likely to die than a baby born to a white mother.

To address health disparities in another aspect of clinical care, nephrology researchers at the Brigham recently examined equations used to estimate kidney function in staging chronic kidney disease (CKD). The findings, which published in the Journal of General Internal Medicine (JGIM), found that the “race multiplier factor” in the equations underestimated kidney function in African-American patients. The findings led Brigham leaders to stop using the factor in the clinic. The change has led to improved care of African-American patients by accurately reflecting the severity of their disease.

Unique Clinical Programs for Inclusive Care

Founded in 2011, the Brigham’s Skin of Color Dermatology Program, led by Deborah A. Scott, MD, was the first of its kind in New England. Its team of dermatologists have training in all pigmented skin tones and provide specialized care for skin and hair conditions more commonly found in people with olive, tan, light brown or dark brown skin. In July of 2019, the Brigham set a milestone when Robert Chelsea became the first Black patient in the U.S. to receive a full face transplant procedure. To help preserve Chelsea’s identity, Brigham physicians worked with him for over a year to find the right color match for his skin tone.

The Brigham has made a commitment to improving health equity and inclusion within the transgender population. While social awareness and inclusion of this population has improved in the U.S., many transgender and gender-diverse people still struggle to access high-quality health care. The Brigham’s Transgender Program aims to raise the level of care for transgender and gender-diverse individuals undergoing the process of gender affirmation. The program’s team consists of specialists from more than 10 disciplines, including primary care, endocrinology, gynecology and plastic surgery.

“The Brigham’s Transgender Program is a medical hub for transgender patients,” said Anna L. Goldman, MD, co-director of the Transgender Program. “Our team of clinicians provides care and monitoring during gender affirmation, but we also refer patients to multiple specialties throughout the Brigham depending on patients’ individual needs.”

Addressing Social Determinants of Health During COVID-19

When the COVID-19 pandemic began, it became clear that racial and ethnic minorities were disproportionately affected. People in these communities are more likely to experience higher rates of housing and food insecurity, incidence of certain diseases and likelihood of being frontline workers, all of which contribute to increased risk of COVID-19. As a result, these populations have higher mortality and rates of hospitalization due to the disease.

“The Brigham is fighting COVID-19 by helping patients who are sick, but also by working together to address the health inequities in underserved communities,” said Cheryl Clark, MD, ScD, director of Health Equity Research & Intervention at the CCHHE. “COVID-19 is a direct health threat to people in our communities, but it’s also created economic instability, poverty and food and housing insecurity for underserved populations, especially Black, Latinx and indigenous populations.”

Early in the pandemic, the Brigham co-led the establishment of the Mass General Brigham Equity and Community Health COVID Response Team. The response team worked quickly to engage with the community. At pop-up sites in Boston neighborhoods, the team offered COVID-19 testing. They also provided screening for housing, food insecurity and other factors that influence health outcomes.

Increasing Diverse Representation in Clinical Trials

The Brigham has long been committed to making sure that diverse populations are represented in clinical trials. Most recently, the Brigham was the only hospital in New England to serve as a site to test the mRNA-1273 vaccine for COVID-19.

“The Brigham ensured that participants who were at the greatest risk of acquiring COVID-19, especially those from communities of color, had an equitable opportunity to participate in this vaccine trial,” said Lindsey Baden, MD, MMSc, director of Clinical Research in the Division of Infectious Diseases. “Over 30 percent of this trial’s enrollees were from populations that suffered a greater burden of infection during the pandemic.”

At the Brigham’s Division of Global Health Equity, Bisola Ojikutu, MD, MPH, an infectious disease physician, leads efforts to engage Black and Latinx communities in clinical trials. Dr. Ojikutu published a paper in Europe PMC that addressed deeply ingrained medical mistrust among Black Americans living with HIV. She is currently leading a national effort to develop strategies to address vaccine hesitancy within the Black community.

The Brigham’s COVID-19 Vaccine Equity Team addresses disparities by partnering with community organizations to host town halls and educate the public about COVID-19 safety and vaccine trials. “We were able to successfully engage diverse communities in Boston to participate in COVID-19 vaccine trials,” said Paulette Chandler, MD, leader of the Community Engagement & Education for the Brigham COVID Vaccine trials.

Measuring Health Equity at the Brigham

While a number of initiatives and programs have been established to promote equitable care at the Brigham, it’s important to make sure that existing programs are held to the same standard. The Brigham’s Health Equity Innovation Program supports projects that examine structural inequities in existing programs at the hospital. The program also proposes targeted interventions to address any areas that may need improvement.

Medical and research institutions have a long path in front of them to address structural racism in the health care system. The Brigham has committed to addressing health equity and racial justice issues on numerous fronts. In addition to providing equitable care for patients, the Brigham continues to invest in innovations that break down structural inequities in order to address the root causes of health disparities.

“The challenging work of improving health equity in research and clinical care requires open and honest communication between clinicians, researchers and patients,” said Dr. Ojikutu. “It’s important that members of our communities know that this work is for them. It’s an ongoing partnership between the Brigham and the patients we serve.”

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