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Healthcare Disparities: The View From Harlem, NYC – Part 2

Stroke is the leading cause of adult disability in the United States and the third leading cause of death. Worldwide, stroke is the second leading cause of death. Like heart disease and cancer, serious stroke disparities persist in America. African Americans have a relative risk of stroke death that is 4 times higher that whites at ages 35-54, 3 times higher at ages 55-64, and 2 times higher at ages 65-74.

The reasons for this are the focus of my two blog posts.

Over the last decade, most of the research dollars spent on stroke has focused on treatment and recovery. Researchers have spent millions trying to come up with new blockbuster treatments that reduce stroke burden or reverse it’s disabling impact. Therapeutic clot-busters have emerged with narrow time-windows within which they must be administered. Relaxing these time constraints have been the subject of even more research, and stroke recovery laboratories explore brain re-learning, neuronal plasticity, and cellular regeneration.

While I believe that we must continue to remain leaders of new and innovative treatments of disease, there is no doubt in my mind that the best return for our healthcare dollars is prevention. It is the only thing that can reign in the runaway disparities in healthcare and reduce the physical and economic burden of disease among all Americans.

But prevention is complex. It is much more challenging than administering a clot-buster or taking a cholesterol-lowering drug. Prevention involves the entire community – the whole ecosystem. It involves the child or individual, his parents and grandparents, his schoolteachers, his neighborhood stores and local parks, his local government policies, his primary care physician, his local community clinic or hospital, his employment status, his wallet, and lastly, his genes. Compare this to treatment, which involves having access to particular medical interventions such as a drug or surgical procedure.

Stroke prevention can be subdivided into primordial prevention (preventing stroke risk factors like high blood pressure, diabetes, and obesity, from developing in the first place through healthy living), primary prevention (preventing a first stroke by treating identified modifiable risk factors like high blood pressure etc), and secondary prevention (preventing a second stroke from occurring by controlling risk factors and administering specific treatments like taking a daily aspirin or having surgery to open up clogged arteries in the neck).

For the purposes of this post, I will focus on primordial prevention. To begin, I will re-introduce the root causes of disparities outlined previously:

  • Educational status
  • Employment status
  • Insurance status
  • Income level

How do these factors influence primordial prevention? How do they interact to define ecological conditions within a specific community? How did they contribute to the young boy’s adolescent stroke? To begin, I will list factors endemic to the young boy’s environment:

1] Low Health Literacy – the “hidden dragon” of all treatable risk factors; so often underestimated and so dangerous to the beholder.

2] Unacceptable numbers of uninsured – the “crouching tiger” threatening to tear down the entire health system

3] Poor access to care – an unforgiving predicament.

4] Limited access to healthy and inexpensive food

5] Ubiquitous access to unhealthy and cheap food

6] Low levels of non-occupational physical activity or leisure-related exercise

7] High tobacco and alcohol consumption.

8] Chronic persistent stress levels that overwhelm coping mechanisms.

In a study by Mauricio Avendano and Maria Glymour, wealth and income levels were shown to be independent risk factors for stroke. Another study by Glymour, Avendano, Haas, and Berkman showed that childhood social conditions (southern state of birth, parental Socio-Economic Status or SES, self-reported fair/poor childhood health, and attained height) predicted stroke risk in black and white adults. Moreover, adjustment for adult SES, in particular wealth, nearly eliminated all the disparity in stroke risk between black and white subjects

The ecological conditions that shaped the young boy’s physical and limbic traits are examples of an uneven playing field. He was born into it – just like I was born into my little world. The sporadic binging on cheap ubiquitous fast food whenever his mom had a little money and the absence of playtime ultimately led to his childhood obesity. The complex conditioning of his limbic needs led to a psychological fragility that was encased by a shell of defensive behavior that in-turn caused truancy.  Substance abuse was around the corner waiting patiently for him. By age 15, the young boy was already a user; with open arms he was welcomed into “the hustle”. Mom was broken. One could see it in her eyes. She no longer worked. She no longer cared.  That is, until her son had a stroke when he was just 17-years-old – the day the drought ended, and she cried.

It was a hemorrhagic stroke. The high blood pressure in his brain arteries caused by accelerated atherosclerosis – the consequence of his substance abuse (tobacco, alcohol, cocaine), type-two diabetes, and undiagnosed hypertension – was what caused the stroke. The stroke was so large that it shifted half of his brain across the midline of his skull, crushing it against the inner-table on the other side.  Fortunately (some would say), the kid survived. Unfortunately, he wanted to die – 17-years-old and nursing home bound, unable to speak or swallow or move his right side.

The stroke was the final blow dealt by a cascade of disparities all too common in America.

Healthcare Disparities: The View From Harlem, NYC – Part 1

Disparities in healthcare are composed of several interconnected layers – multiple layers joined together like the bricks of a divisive wall, separating better health from poor health.  And while we must acknowledge the pre-eminence of personal responsibility, we must also address the uneven distribution of mountains and valleys on the American playing field.

Disparity sometimes begins before one is born; before one is conceived – it may begin in-utero, with the absence of adequate prenatal care, with maternal co-morbidities and high-risk behavior, long before one is old enough to assume personal responsibility within an “inherited” landscape or community that is filled with steep climbs and dark valleys. Many of us are familiar with root causes of healthcare disparities – the four components or foundational bricks that sustain physical and economic health in capitalist societies.

  • Educational status
  • Employment status
  • Insurance status
  • Income level

Individual or combined deficits in these components typically lead to accumulating disadvantages within which good health is considered an outlier. It is often these environmental factors, and not genetic ones or racial ones that are largely responsible for the disproportionate morbidity and mortality we witness all over America – especially in Harlem – the site of my neurological practice.

A young child is born on Malcolm X Boulevard in central Harlem. He is the most beautiful baby I have ever seen. And yet, his passage into the world is not without hardship. His single mom, a sixth grade dropout, did not have health insurance even though she worked two minimal wage jobs.  She did not receive adequate prenatal care. Indeed, the only time she visited the hospital was to fix the broken bones in her face she sustained from domestic violence.  Fortunately, she escaped from that life by fighting back with everything she had. Even her child was born through conflict – amidst the peril of eclampsia. It was a stormy delivery in a safety net hospital. Luckily, she survived and the beautiful baby boy thrived.

The early years of the child’s life were spent with grandma, until she died when her grandson was only 9-years-old. Mom had nobody else to help her, and there were no breaks in Harlem. She could not afford the childcare she needed to keep her second job, which she fought so hard in vain to keep.  She became homeless. After squatting with her son in an old boyfriends house for a period of time, they finally moved into a housing shelter and were placed on a waiting list for section 8.

Mom was born poor; she had no successful role models; no good yardsticks with which she could measure herself against. Everyone around her seemed resigned to the status quo, which they would refer to as “the hustle”. She did not make it to high school; she fought for her minimum wage; she had no health insurance; and yet she worked hard to provide basic needs for her and her son. Each brick of disparity – educational status, employment status, insurance status, and income level – formed a wall so tall that it was hard to imagine how she would get to the other side.

Depression crept in – an irrepressible feeling of worthlessness and hopelessness. A feeling that no matter how hard she tried she would always fail.  Most of her girlfriends were already on the streets or in jail. Their children had dropped out of school to join gangs or resort to petty crimes. She promised her own mother long before she died that she would never resort to crime. She would fight a good fight for her son and herself. But depression dug deeper, breaking her will, piece by piece until she finally succumbed to the twin pressures of emotional and economic desperation.

We all have limbic needs. For some, these needs are nurtured by loving hands that paint lasting portraits of hope inside our souls. Expressions of hope hanging on the walls of our heart chambers: a mother’s attention; a father’s approval, a caregiver’s warmth, a schoolteacher’s encouragement. For other’s, there is insufficient nurturing – these limbic needs are not met; rather, they are torn down – left out in the cold, often on impoverished streets – unanchored, undermined, forced to adapt alone in a Darwinian society.

In my next post, I will finish this story. I will describe the boy’s life and his ultimate stroke in an attempt to show the interconnectivity of health and the four components of healthcare disparities.

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