What prompted one of America’s most accomplished and acclaimed physicians to pursue his career path?
“My mother was a nurse and that’s what personally motivated me to get involved in medicine and public health,” says Dr. Garth Graham who, as Vice-President and Chief Community Health Officer for CVS Health, led public health partnerships and cardiovascular initiatives for the largest retail pharmacy in the U.S before joining Google/YouTube as its Director and Global Head of Healthcare in January. “I am not sure at what point I decided to pursue medicine, but I think watching my mother over the years made me establish that as a goal.”
Born in Jamaica, Dr. Graham moved with his family to Miami where he would attend Florida International University before pursuing his Master's in Public Health (MPH) from Yale University, working as an attending physician at Massachusetts General Hospital and beginning a meteoric rise in public health. Dr. Graham served as Deputy Assistant Secretary of Health in the U.S. Department of Health and Human Services (HHS), overseeing the Office of Minority Health in both the Bush and Obama administrations, and went on to become Assistant Dean for Health Policy at University of Florida School of Medicine, Vice President of Community Health at Aetna (acquired by CVS in 2018), and president of the Aetna Foundation before joining CVS in 2018. At YouTube, which is owned by Google, Dr. Graham will lead clinical and public health strategies and partnerships.
A cardiologist, he was a board member of the National Heart, Lung and Blood Institute Advisory Council, the American Heart Association/American Stroke Association National Quality Oversight Committee and the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards. He also chaired the Harvard Medical School Diversity Fund and was named to the U.S. Federal Coordinating Council on Comparative Effectiveness Research by President Obama.
At the University of Florida, he led research initiatives looking at how to improve outcomes and readmission rates and cardiac patients and underserved populations. In interviews and speaking engagement, Dr. Graham frequently cites his parents as sources of wisdom who instilled the importance of education.
Regis professors Lisa Fardy and Shannon Hogan recently met with Dr. Graham for a wide-ranging conversation about racial disparities in healthcare where he reveals why, “Black and brown students in Pre-K, elementary and first, second grade are probably doing much more to eliminate disparities than doctors like myself or people who are treating diseases once they have emanated” and that “your zip code is still a major driver of your mortality and morbidity.”
Dr. Lisa Fardy: We're exploring with you a bit more fully the concepts of social determinants of health and health equity, concepts that certainly shape and form not only my teaching but also [my] professional practice. I must confess, however, that while social determinants and health equity were explored in my nursing studies, I didn't delve as fully into how determinants and equity truly impact health, healthcare delivery, and health outcomes until I began my Master of Public Health program. With the recent addition of social determinants and health equity to Healthy People 2030 aims, I'm encouraged and hopeful that more rightful attention and action will result.
To begin, Dr. Graham, please highlight a bit of your professional journey into exploring and examining [social] determinants of health and health equity.
Dr. Garth Graham: Sure, and thanks for arranging this discussion. I started off my career clinically as a cardiologist, but early on in my residency and training, in particular internal medicine training, got interested in issues of community health, and I started up a project when I was a resident at Mass General around Black men and getting access to fresh fruits and vegetables. And in the midst of that, I started to see on the ground the dynamics of social determinants in terms of health and communities and what was driving individual decision-making had a lot to do with all of those factors that were not clinical in nature although they had significant impact on clinical outcomes.
Now at different points in my career that experience has kind of carried through, and so when I went into federal government, I eventually was leading a lot of the federal efforts around minority health and health disparities at a time when the lexicon of social determinants of health was just starting off. But we were able to work a lot of things, including Healthy People 2020, at the time. The social and environmental factors continue to dominate what drives health outcomes. Kind of a long, circuitous path through different industries but still maintaining a focus, a career focus, around social determinants of health.
Dr. Fardy: I was hoping that before we focus a bit more specifically on the COVID-19 pandemic, that you would be willing to explore a bit more with us the underlying health disparities that actually predate COVID-19 and likely predisposed certain individuals, particularly of racial or ethnic groupings, to actual COVID-19 exposure and illness.
Dr. Graham: My viewpoints on COVID-19 is that COVID-19 is just following every other disease pattern that has disproportionately impacted minority communities, whether it be heart disease, diabetes, obesity, influenza, pneumonia, H1 N1. All of these, both infectious and noninfectious diseases, very much disproportionately impacted minority communities. The only reason—the only difference—is that COVID-19 is getting additional attention. We still continue to see heart disease disproportionately kill Black and brown communities much the same way COVID-19 has been doing so.
Now, what COVID-19 has done is layered on a more timely infectious disease process that has grown into a pandemic and so highlighted the visibility. But we've long—we've long thought that the social and environmental factors that have been driving COVID-19 are the same social and environmental factors that have driven heart disease. There's data around zip code locations. Some data that I published in my research career around this impact on mortality and heart disease, it's very similar. So suffice to say that the disproportionate disease burden is longstanding, long documented, driven by much of the same factors - i.e., higher chronic disease, impact of housing, education, transportation and other things.
Dr. Fardy: I follow the work of Dr. Uché Blackstock quite closely, an emergency room physician and an urgent care physician based in Brooklyn, New York. And I’ve followed her quite consistently since the pandemic surge began. And I remember reading some of her early postings saying that she, as a Black woman, couldn't ignore the reality that more and more of the patients who were presenting with what appeared to be consistent with COVID-19 signs and symptoms looked very much like her and her community and that it wasn't coincidental.
Dr. Graham: Yeah. And I think the velocity, the speed, and the mortality and morbidity related to COVID-19, I think, has been more jarring. And especially when you see 75% of the children being impacted coming from Black and brown communities. You know, those statistics are baseline moving but more importantly, motivating in terms of how do we create a better healthcare system overall?
Dr. Fardy: In a letter that I'm sure you're very familiar with dated July 17 of this year to the Senate majority leader Mitch McConnell and the Senate minority leader Chuck Schumer, the American Medical Association, the American Nurses Association, and the American Hospital Association outlined seven areas in which to partner together to address the ways in which COVID-19 disproportionately affects racially and ethnically minoritized and marginalized communities. COVID-19 tracking data indicated that “Black people are dying at a rate nearly two times higher (24%) that their share of the population (13%), and that in 42 states, Latinx people make up a greater share of confirmed cases than their share of the population.” The letter went to state, “Similar inequities are beginning to emerge in state-reported data for Native Americans and Asian Americans, although the data are not granular enough to ascertain which Asian American communities are most impacted. We note that in some cases, providing inpatient care to patients who are historically medically underserved will prove more costly.”
I don't think that the letter was any surprise, but I suppose my question, if you’d indulge me please, is how much of the COVID-19 racial and ethnic disparity do you believe is attributable to health inequity within the actual healthcare system?
Dr. Graham: Well, that's a good point. You know, I think this is all a continuum. I think the inequities that show up in the healthcare system are reflective of the inequities that are broadly impacting society at large—again, education, housing, transportation—all of those social factors that then are just measured in the healthcare system if that is the lens you look at it from. But it could also be measured in the educational system if you want to look at it from that lens. And maybe--can be clearly indicative in economic dynamics that are more historically tracked if you want to look at it from that lens.
I think the difference is that the healthcare system, in many times, gives us more visual—and sometimes because of the way we track data in healthcare—some points to continue to track along with. But all of these are kind of reflective of various social and environmental dynamics. So, David Williams, for a lot of us, I’ve been a part of his work. My father does work and has been involved with his work for many years.
David is one of the researchers from the Harvard School of Public Health, and David traces a number of this back to the propagation of continual segregation in Black and brown communities. So, showing that elevated segregation indices—meaning the ways in which we live in, in equanimity or, or the ways in which Black and brown communities are mixed versus segregated—that we are still very much segregated, and I'll compare it to where we were in the 1960s just in terms of living patterns. And so that generates a number of different outcomes that, that you see, including COVID-19, but again, and I could tie this into graduation rates for, for Black men and, and give you a similar corollary in terms of impact. And then I could then tie graduation rates to health outcomes that apply to that seven years’ difference in life expectancy based on if you graduated versus not, graduated high school versus not. So, there is a nascent or longstanding interdependence of a lot of these activities or impacts, but we just differentiate them depending on which lens we look at.
Dr. Fardy: There’s been increasing and rightful discussion about systemic racism within communities and countries. But if we focus more on systemic racism in healthcare, what do we find?
Dr. Graham: The issue of health disparities and the impact of racism in health and healthcare policy overall has been well defined. I think there’s a number of different ways to look at it. The difference in diseases, whether you talk about infant mortality, maternal mortality, cardiovascular disease, diabetes, or any of those related entities and the disproportionate impact that it has on the minority communities and the role that race, racism, location, geography, all those related issues have played in that context. In summary, I would say, at least in clinical medicine, racism or the potential stress of racism has been linked to issues like higher rates of infant mortality and higher rates of maternal mortality, just picking those two disease entities. I think there’s also the issue of the role of cultural competency and implicit bias and how that, as a form of structural racism, has played a role in clinical care. So, I think that there’s a defined and definitive role for the impact of structural racism in healthcare.
Dr. Fardy: On September 21 of this year, Mark Emerson and Melissa Troester concluded that Black women have a 42% higher breast cancer mortality rate than white women despite similar incidence rates and among women under age 45, Black women sustained a breast cancer rate more than twice that of white women. The study pinpointed three specific issues associated with prolonged breast cancer treatment among Black women, namely lack of insurance, transportation challenge, and financial strain as counted by the wealth gap between Black and white families in the United States today. How does the healthcare system begin to address this disparity?
Dr. Graham: I will say that there are additional challenges beyond insurance and transportation that drive the disparities between Black women and breast cancer. One, I think you alluded to this, but the issues around screening and the fact that they initially present at a more advanced stage, and particularly among young women, more aggressive disease. The other is issues around quality of care, and the third, I would say, Black women have the highest probability of getting triple negative breast cancer, which is a particularly more aggressive kind of breast cancer and the one that has the highest mortality.
So, I think there’s kind of a multitude of factors, a multitude of challenges, that one has to think through in terms of what can be done. There’s lot of clinical research going on to try to understand this concept of the expression of triple negative breast cancer in Black women and why it’s so aggressive. But one of the things we have to do is— we know the early screening works—so getting more screening is particularly important and also the kinds of things that reduce those risk factors for women, Black women, getting breast cancer. In addition, the social determinants of health issues that you alluded to as some of the drivers not just for breast cancer but for all of those things are always going to be part and parcel of solutions that address any disproportionate impact of diseases between Black and white communities overall. We have to think through, like, how do we emphasize some of the protective factors that may lead to a lower incidence, particularly of triple negative breast cancer?
Dr. Fardy: I wanted to explore a bit of your own research. You used an example of a fifteen-year life expectancy gap noted between Miami, Florida neighborhoods distanced just five miles apart. Would you share the details you were seeing?
Dr. Graham: This is research published out of Robert Wood Johnson basically showing the impact of zip code and life expectancy, and it is replicated in most major cities. In Richmond, Virginia, there’s a 20-year gap in life expectancy between zip codes that are majority white and some zip codes that are majority Black. Similar in Philadelphia, you see that in New York, and Miami is just another example of the urban setting. And all of that data points back to the, I guess, two factors that play a role in all of the diseases that we’ve talked about. But all of that data points back to segregation and the point that many communities continue to live in kind of segregated dynamics, post 1960s. And David Williams and team have published some data looking at the segregation index, and that’s the degree to which you need to move to make a community equal, and how do you determine if you’re going to have equal distribution by race.
All of our major cities are highly segregated in the United States. So that is the basis of the differences in life expectancy, because then, within the segregated neighborhoods, you have lower graduation rates. You have all the social determinants of health factors. And we know that once you’ve graduated high school, you can extend your life expectancy by about eight years between those who have graduated and not. So that data is just underscoring the geographic concentration of communities, how that drives health disparities, and why your zip code is still a major driver of your mortality and morbidity.
Dr. Fardy: As you well know, our COVID-19 pandemic has become a very glaring and daily reminder of unchecked health inequities. When we consider other viral pandemics, could we draw similar conclusions? I know that Dr. Shannon Hogan who is with us today is hoping to pose a question or two regarding this. Shannon?
Dr. Shannon Hogan: I teach a number of courses and one of them is virology. When I teach the course, especially during the pandemic, I remind students that whether you include just the U.S. or, more importantly, the rest of the world, we’ve been living in a pandemic for over 35 years now with the HIV pandemic. And if you look at the data that Healthy People 2020 have used previously to speak about rate of infection and who is getting infected, it would appear that whether you look in the hottest spot on the planet for HIV infection, which is sub-Saharan Africa, or even if you look in the United States, people of color are still more likely overwhelmingly to be infected with HIV versus white people.
What at do you think the reasons are for that to continue? And then, secondly, if you look at the infections in white people from 2014 to 2018, you’re seeing them on the decline, versus if you’re looking at people of color, they’re actually slightly on the incline. So, I was wondering, one, why do you think the persistence is for people of color to be more likely to be infected? And two, why would it possibly, in the United States of all places, be on the incline for people of color?
Dr. Graham: For HIV, there are a lot of different components that I would say go into that. Limited access to housing, high quality health care, HIV prevention--you know, HIV prevention education--are known to increase the risk of HIV infection. I think some of these might explain why, so far, Black communities have a higher impact overall and worse outcomes. There’s also lower rates of linkage to care and viral suppression in Black communities in particular. Some people has postulated whether, you know, stigma, fear, discrimination, homophobia, whether those factors have been playing a role in terms of African Americans and accessing HIV prevention, care, and services.
But then we also have to think about, I mean, some of the other prevention challenges. I think it’s something like one in seven African Americans with HIV are unaware they have it, and so, you know, thinking through how we get testing, treatment, and access are part of both the problem and the solution. But a lot of the challenges that we just talked about for other disease entities, those things overlap data-wise in terms of a number of other diseases. And I think the impact on socioeconomic status, the social determinants of health broadly, I think, is definitely playing a role.
Dr. Hogan: I think I asked basically the same question then in my second question. That would also be the main drivers in why we’re seeing the rate slightly increase in people of color versus white people. Is that correct?
Dr. Graham: Yeah, exactly. There’s a role for HIV prevention and education, and there’s a role for testing. There’s a role for linkage to care and getting viral suppression. We’ve been able, I think, to adequately achieve those linkages stronger in other populations. You know, I think we need to think more about how we get that more to Black and brown populations.
There’s also one other point I would say: There’s a geography to the HIV epidemic in Black communities in the US. The South, the southern part of the United States, accounts for, you know, the majority of new infections for Black communities, and it’s really clustered among a small group of states, Florida and New York being at the top of the lists. A lot of that speaks to the same challenges we just talked about around zip codes, geography, social determinants, and those factors as well.
Dr. Fardy: One example of glaring health inequity is the too-frequent dismissal of minority patients’ pain, particularly that of Black patients. And I know that in caring for patients personally, both pediatric and adult, I’ve seen this scenario play out far too often and, honestly, sometimes resulting in my challenging the health care hierarchy to demand better patient protection. How can health care professionals begin to do better?
Dr. Graham: The facts are that Blacks are less likely to get all kinds of analgesics for pain and that even in a primary care setting, providers are more likely to underestimate the intensity of pain in Blacks than in other areas. But it’s also interesting in understanding how that occurs even in acute settings.
Like, you’re more likely in an emergency room visit that opioids are more likely to be prescribed to patients from higher economic status. I think what this points to is the issue of cultural competency and providers, particularly on the front lines, understanding the degree and the context to where implicit bias may be playing a role. It’s normally implicit, not necessarily explicit, bias, but understanding the culture of the presenting patient and treating that patient appropriately.
You know, sickle cell is a disease where the pain levels have been on many times, as you know, undertreated, and there’s even been some data where people, even medical students and medical trainees, think that things like even thicker skin or less sensitive nerve endings may be present in Black versus white, which is an entirely false notion. There was an interesting paper that came out before. So I think it’s about understanding, awareness, education, particularly I would say at a medical school level given that medical school trainees have also been shown to believe some of these myths and then having that implicit bias, both training and understanding, go all the way up to the more experienced physician.
Dr. Fardy: Where would you say, based on your very storied career to date, where could an individual or a group of individuals make the greatest impact on social determinants of health and health equity, particularly amid our global pandemic?
Dr. Graham: Oh, wow! You know, I think there are so many different roles and responsibilities that it’s really creating a very broad team effort. I would say that teachers who are teaching—I would say particularly Black and brown students in Pre-K, elementary and first, second grade—are probably doing much more to eliminate disparities than doctors like myself or people who are treating diseases once they have emanated. That’s because the words you learn dictate whether you graduate from high school, and graduating from high school is one of those predictors for how long you live and a lot in terms of disparities. So I think you can pick from a lot of varied professions along the spectrum of improving both issues related to disparities, issues related to poverty, issues related to social determinants, and plug in your skill set on any degree on that spectrum and have a major clinical impact. But I could think of it from teachers to pharmacists to cardiologists like myself to people involved in policy like myself, but I definitely think education is probably one of the more important factors for dealing with issues around health disparities.
