Welcome to Yale Cancer Center Answers with doctors Francine Foss and Anees Chagpar.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This week, Dr. Chagpar welcomes Dr. Lovell Jones.  Dr. Jones is Director of the Dorothy I. Height Center for Health Equity & Evaluation Research and Professor in the Department of Health Disparities Research at the University of Texas MD Anderson Cancer Center.  Here is Anees Chagpar.
Chagpar        Why don’t we start off by talking about what it is you do?  What are we talking about when we talk about health equity and what are we talking about when we talk about diversity and disparities?  What do we mean?
Jones            The idea of health equity is to address the issue of disparities that we see in this country between populations, whether it is ethnic or racial populations, whether it is rural versus urban, whether it is upper-income neighborhoods versus low-income neighborhoods.  America is getting to a point where unless we begin to solve these issues, we may have problems.  Right now the projected cost, GDP, is roughly 18% to 19%, in terms of our gross national product.  Every economist that you talk to will tell you that if we get to 25%, we will become a debtor nation.  And what we mean by that is that our resources will be depleted, we will have nothing to replenish the nation.
Chagpar        Health care costs are rising and this is a significant issue particularly in today’s economy and many of our listeners are thinking about the health care cut backs and the Affordable Care Act and the sequester.  How much of that is related to differences in access to care, and differences in quality of care due to disparities among populations?
Jones            It varies depending on what you talking about and that is one of the main issues, people try to pigeon-hole it in terms of access to care or biological or sociological factors and really it is all of them, it just varies depending on where you are.  Take breast cancers for instance, if you look at the mortality rate for breast cancer say from 1995 to early 2000, around 1995 unbeknownst to most people, the breast cancer mortality rate for African Americans was lower than it was for white women in the city of Houston.  Now the mortality rate is twice that of white women, but the mortality rate for white women in Houston is twice that of the mortality rate for white women in New York City, which means the mortality rate for black women is 4 times that of white women.  Is that a biological issue?  It may be to some extent, but genetics do not change within the span of two decades.  So something else is going on and the speculation may be in terms of personalized medicine, because African Americans have a small amount of disposable income and that is where most of the ability to get personalized medicine comes from in terms of yearly disposable income, but let’s go to Maryland where the incidence of breast cancer among young women in Maryland is very high and so people have thought, well it might be environmental issues because they do not
see that much difference between blacks and whites.  You have to first define what is black and
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white, because most people do not realize that Maryland, being a Catholic state, a lot of white women who came into Maryland, came in as a indentured servants.  They were Scotch-Irish and a good number of them had relationships with African slaves, Benjamin Banneker is probably the most noted offspring, but those individuals who came into Maryland, the slave population, a large percentage of them came from an area of Africa where the incidence of premenopausal breast cancer occurs in somewhere between 40% to 45% of the women who show up in the clinics, but we should also note that the Scotch-Irish have a high percentage of BRCA genes.  So, you put those two populations together, and what happens is people begin to be defined not on the genotype but the phenotype.  So those who were light got characterized as being white and those who were dark were characterized as being black.  So if you just look at it in terms of phenotype then you may be making assumptions that are totally wrong, because you’ve now characterized them as being black and white and they are suffering from the same problems, that they may not be genetically related and therefore you look for other external issues and that’s not to say external issues may not play a role, but you throw out the historical perspective that contributes to it and that is one of the things I have been pushing is that we need to begin to look at this in abroad sense involving anthropologists, health policy people, those nontraditional areas to get involved in the discussion, psychologists, because they may bring clues to the solution that we would not look for if we did not have them in the room.
Chagpar        I think that when you start unpacking all of this, what you realize is that it really is a whole myriad of issues at play, as you say.  We see a higher mortality amongst African American’s for almost every cancer, is that because there is something genetic about African Americans, and maybe this can relate to the Scottish-Irish that you were talking about in Maryland who may have some African-American genetics in their history, or are all those other issues at play, differences between Houston and New York for example may play into body mass index, may play into socioeconomic status.  How do you start to unpack all of those issues that can affect outcomes?
Jones            Well as Tip O’Neil said, all policies are local, and as I say all health is local and we try to solve things through databases, national databases.  To give you another example, in terms of the Houston County, Harris, we often talk about African American women having a higher mortality rate and low incidence.  Well, in Harris County this is not the case.  Their incidence rates are higher than in white women as well as the mortality rates, but if you went along with the national data you would totally ignore that in terms of what is going on, and so trying to find a solution to the problem we could then say, “Well maybe it is only access.”  And we have looked at the number of available screening slots in the Houston area, there are more screening slots than women.  So it is not an issue of the slots and so you have to redefine access, what is the issue?  Houston has one of the highest percentages of individuals that do not have insurance and so you say well, they may be poor, working poor, because Houston also has the highest number of small

businesses and small business do not have insurance coverage and then you say, well there are charity services but when you go back and look at the screening services, most of them are open during business hours, very few open on the weekend or in the evening, and so if you have a population that loses money because they go to be screened that day and do not work, they are hit doubly.  They pay out of pocket for the screening cost and they have lost that day’s work.  So, would you go into get screened? Not if you don’t feel you have a problem.  So, these are multi issues and then you come up with the idea that there may be a higher propensity for that disease and so they do not get screened, they show up later and then you begin to blame the victim, they did not care about their health, but maybe they did but there are issues that contributed to them not being able to seek care. And the discussion now that I have been involved with is you say, “Well with the Affordable Care Act everyone is going to be insured, well not in Texas.  We project that even if the Affordable Care Act is implemented in its fullest extent, we still will have over two million individuals who will not be insured.
Chagpar        Because.
Jones            They fall in that donut hole, they earn too much for the subsidy for the exchange and they may not earn enough to pay for the exchange so they would probably rather look at being find and hope that the fine is smaller than the fee that they would have to pay to be covered.
Chagpar        The more you think about health policy and access and insurance, you’d think that finances should really not get in the way of good medical care and your health.  It seems to me to be an increasingly difficult problem to solve.  So what is the answer?
Jones            It is not that it is a difficult problem to solve, we have the knowledge to solve it, we just do not have the will to do it and I think it all comes back to how we evaluate human life.  In this country we are still at the point where we value individuals in different ways, and you see it both consciously and unconsciously. There was a recent article, I am trying to think of the investigators out of Harvard who actually developed a scale that individuals can take to see what their biases are, unconscious bias, and they started looking at how individuals in terms of preference and saying, I will do this for my friends, well who are your friends, think about that.
Chagpar        We are going to come back and talk more about conscious and unconscious bias and how that affects cancer and disparities after we take a short break for a medical minute. Please stay tuned to learn more information about health equity in cancer with our guest Dr. Lovell Jones.

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Chagpar        Welcome back to Yale Cancer Center Answers.  This is Dr. Anees Chagpar and I am joined today by my guest Dr. Lovell Jones.  We are talking about the whole issue of health equity in cancer and why to this day in 2013 there are still disparities amongst various populations. Lovell, during the break one of the things that you had said which I think really struck a chord was this is not a black problem, this is not a minority problem, this is an American problem.  Talk more about that and why this really is an issue that affects all Americans and give us some guidance on what people can do to make a difference.
Jones            I think we need to go back and look at how we practice medicine and the policies behind the practice of medicine and how we as individuals, whether we are in the health arena or not, support this and allow this to take place.  When we practiced medicine based on an infectious disease model, you could be on the farthest reservation, you could be on a mountain top, you could be in the most rural community, we wanted to make sure that you have been immunized, there were no if and or buts, it didn’t matter if you were black, white, you are going to immunized.  Simply because we did not know when we would come in contact with you, a family member, a friend, a colleague, or someone, and when we started practicing medicine based on chronic disease, we lost that personal contact and we began to say, it is your cancer, it is your diabetes, it is your hypertension, it does not affect me.  Although we realize now that it does affect us economically, it affects your health in terms of those individuals that we do not care about, tend to begin to clog the emergency rooms, especially our Level I Trauma Units and those Level I Trauma Units are not just for poor people, not just for blacks or Hispanics, documented or undocumented individuals,  they are for you when you have a major trauma, that is where you want to go, you do not go to your boutique hospital where you go just for your flu shots and those sorts of things.  This is where you go to save you life, but those units across the country are becoming fewer and the diversion is getting greater and I remember a story that was giving to a lay audience, a very wealthy lay audience and at the end of my presentation an individual came up to me and said, I hear what you are saying, but the rest of my friends do not, and I looked at him and I said, why do you say that, and he says my son died from a health disparity.  This was an individual who was the CEO of a Fortune 500 company, he did not lack insurance, he did not lack coverage, and his son suffered a major head trauma and both Level I Trauma Units were on diversion, the closest Level I Trauma Unit that was open for his child was in Dallas.  He had a Learjet, he could put his child on that Learjet but somewhere between lift-off in Houston and landing in Dallas his son died, that is a health disparity, but we do not think about that as heath disparity, we characterize it as being an

African American issue or a poor people issue or a document issue, when it truly in an American issue and is becoming more and more that way as we become a more diverse society.  The decision in 1965 by Lyndon Johnson to push and sign legislation with regards to immigration policy set us on that course and that course is not going to change.  We have more individuals of color born in this country then immigrate, so closing the border is not going to change the demographic pattern, as it is already in place and so we have to get the idea in our minds that this ship is for everyone and unless we begin to look at solutions to the problems, solutions in our communities. When I give talks I often say, think of two to four things you can do in your community.
Chagpar        Right.
Jones            Because if you start doing it in your community and start caring about that then it will spill over into other communities and then we will start to have solutions to the issues as opposed to saying, that is their problem or their issue, or why don’t they do something about it or, they don’t care about their health, and a whole list of other reasons that come into play.  I was talking earlier about unconscious bias.  The idea that we go into an elevator and there are maybe three or four black men in the elevator and a white older female, even though they are in Brooks Brothers suits will go to the other side.  We all suffer from bias, it is not that we suffer from bias, it is what we do with it.  I have a bias, I will give you an example.  I got home late one night, late in that it was dusk,  and at the time there were a lot of stories on the television about carjacking’s and home break-ins and as I was driving into my driveway, I noticed these four young men coming down the middle of the street in my subdivision and their pants where going in a different way then I normally have my pants, and I began to think and looked at the end of my driveway, my newspaper hadn’t been picked up that morning and I say, should I shut my garage door and let them go by or should I walk out and get my newspaper? I am sitting there having an argument with myself and I give these lectures all the time and I knew I was being biased but you cannot be too careful, and I sat there and came up with the stupid idea, and said well I will go and get my newspaper and hope that the back gate of my yard is open because I probably can run faster than they can, it is a short distance to get to my gate, and as I  bent down to get my newspaper, one of the young man says, “Hi, Dr. Jones.” It was my next door neighbor; it just shows you how those biases can really take hold.
Chagpar        Yes sir they can.
Jones            We are all humans, it is not that we have them, it is what we do with them and how it plays out.
Chagpar        Talk a little bit more about that, how does is play out in healthcare, give us some examples of what solutions people have come up with when you give those talks and you say, come up with two to four things you can do in your community? What are things that people can do in their communities, that will help improve health across populations?
Jones            The idea is, do not make assumptions.  Base your opinion and your decision on a personal feeling.  I will give you a personal example, my wife is a high risk patient.  Her aunts, her mother, grandmother, all have died from breast cancer and she is a very high risk individual, therefore we have her screened regularly and I usually go with her and then one day I set up an appointment and she had to go by herself, so I said just go and I have my cell phone do not worry, if something is wrong, I will be there. She called me from the insurance office at my institution and I saw the number ringing and my heart starts pounding and I think, this is it, I have got to go with her and she says, you do not need to come, I am with the credit counselor, and I said, what are you doing in credit counseling, and she said I did not pay the insurance bill.  I said what insurance bill did I not pay? She says, the one that covers us, I said I don’t pay the insurance bill, it comes out my check, she says they told her that something is wrong with the insurance.  A I am talking to her, I can hear someone in the background say, Ms. Jones, is your husband by the name of Dr. Lovell Jones who works here. Oh there has been a mistake, I am sorry.  She said, I do not know where they are taking me but I am gone, so I went to the clinic and I am sitting across from the clerk and I said where is my wife? They said, “I am sorry she has gone, and by the time I am asked another question, the phone rings, it is my wife, she says, I am on my way to the Galleria and everything is fine.  So I turned to the woman and said, why was my wife not seen immediately? Well, there was something with a Co-Pay, I said how much was a Co-Pay? Well, it was a year ago or two years ago it was $25.  I said, my wife could have written you a check or you could have seen her after.  And they said, well you know Dr. Jones 50% of all Hispanics do not have insurance coverage. I said, what does that have to do with my wife, she is not Hispanic? Well, you know.  I said stop there, stop right there.  By that time, a colleague of mine comes out because they heard me raising my voice.  He said, what is the problem?  I said, the problem is profiling. You profiled my wife, and I am not going to let that leave my mind, because I could do something, but what about the other people who come here and cannot do anything about that?
Chagpar        Right.
Jones            And so the issue is not so much whether one was covered or not covered.  It is the impression that you have when they come, and I tell people if there is one thing you can do, it is to check your own biases.  Not that you are going to get rid of them, but see how they play out in terms of how you are dealing with people, especially in terms of healthcare.  Housing, you can go to another house, schools, you can go to other schools but when it comes to your health, that is a critical issue.  There is no room for that.
Chagpar        I think that is profound advice, particularly for those involved in healthcare, doctors, nurses, even the person at the front desk, the security guard at the hospital, how they treat people as people, because we are in a people profession, in the profession of helping people and making them better.  I want to get back a little bit to the disparities that exist even with people who have access to care, people who are treated with the greatest amount of respect, where we are still seeing differences on a population basis and I wonder whether part of the disparities that we see are related to the fact
that more African-American and Hispanic people tend to be uninsured, and therefore, may get less screening and may have higher mortality rates, or even that poor Caucasian people face incredible disparities when it comes to healthcare compared to their richer counterparts.  Can you talk a little bit about that and what you see as potential solution from a health policy perspective that will address this “American” problem?
Jones            One key issue is increased amount of money spent on prevention.  For example, for cervical cancer, a Pap smear is $45 or less, stage I cervical cancer treatment, noninvasive, about $2500, and stage II and above $185,000 to $235,000.
Dr. Lovell Jones is Director of the Dorothy I. Height Center for Health Equity and Evaluation Research and Professor in the Department of Health Disparities Research at the University of Texas M.D. Anderson Cancer Center.  If you have questions or would like to add your comments, visit yalecancerventer.org where you can also get the podcast and find written transcripts of past programs.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.