Dampening Health Disparities

Dr. David Lewis is distinguished professor of Psychiatry and Neuroscience, chair of the Department of Psychiatry, medical director and director of research at UPMC Western Psychiatric Hospital. He's also a board member of the Pittsburgh Foundation. Cristina Rouvalis recently sat down with Lewis to discuss one of his passions - the need to close the equity gap in medicine

Cristina Rouvalis: Dr. Lewis, what does medical inequity mean to you?

David Lewis: It’s a very broad topic that I think can be conceptualized as anything that impedes a given individual's capacity to receive the medical care, and by medical care I include behavioral health care, that they need. 

CR: Can you give me some examples? 

DL: There are a number of examples, unfortunately. In our own community, where we have food deserts, people don't get the appropriate nutrition that they need; areas where there isn't adequate recreational facilities so that people have a harder time getting the exercise that they need to stay healthy; [places]  where we have limited access to medical care; the quality of the air varies across southwestern Pennsylvania in Allegheny County. And so there are areas where people live where the air quality is not as healthy or, frankly, unhealthy.

CR: And what does that mean for them as far as medical outcomes?

DL: There is greater risk for a variety of respiratory illnesses associated with higher areas of air pollution. For kids [there is a] greater likelihood of asthma, or more severe asthma. There's even some evidence, not here, but nationally, that rates of autism are higher the closer one was born and lived near a freeway. The illness that I study, schizophrenia, for reasons that we don't understand, the rate of schizophrenia is highest for people who were born and raised in a high density area, like a major city, as opposed to less populated areas. So there's a range of factors that can affect a life course of an individual. Also rural areas, we are very blessed to be in Pittsburgh and to be surrounded by all these great hospitals and we can get there pretty quickly. But what if you live three hours away? Transportation [and] access to medical care become issues in rural environments. We have some inequities or discrepancies in terms of the extent to which people have been exposed to opioids and are at risk of opioid addiction, and at least for a period of time that was accentuated in rural communities. The quality of education is important across the board for lifetime health. And so depending upon what educational resources are available in rural areas versus suburban areas, versus, you know, high density city areas. And of course, there's a range of ways in which those areas differ in educational opportunities.

CR: Can you talk about any other social determinants of health, like being close to firearms, or, as you mentioned before pollution?

DL: There are very local factors...people who live in a home in which there are firearms are much more likely to be harmed by a firearm, either accidentally or there are over 50,000 people a year in the United States who die by suicide. And one of the factors that predicts successful suicide is access to lethal means and firearms are the most lethal means. We have smoking, even though the rates of smoking have gone down in our country - secondhand smoke, being raised in a home in which there are smokers creates increased risk for poor health outcomes. Nutrition in the home, parenting and depending upon a given individual's experience, and especially the education that they've had about being a parent, and the resources that they have to manage parenting, all have an impact on the long term health of their children in mental health or just any kind of health, especially mental health. There are mental health issues that confer risk for men -  critical issues - kids who are early exposed to drugs are more likely to have accidental causes of death in association with those, particularly alcohol.

CR: What are the challenges to eliminating those disparities?

DL: Well, there's so many challenges, one is actually conducting the science that helps us make clear links between what the risk is and how the risk translates into illness so that we have a better idea about how to make interventions and where and what time we should make preemptions to try to prevent risk. So much of medicine today is still about treating people who have developed problems. But the goal of medicine really is to be preemptive - to identify individuals who are at risk, identify what the risk factor is and intervene to reduce the risk factor before the signs and symptoms of the illness occur.

CR: Can the Pittsburgh foundation be a source of grant making to eliminate some of these disparities? In what kind of research could a donor support?

DL: I think that the Pittsburgh Foundation has and will continue to do a number of great things to reduce health inequities and promote health for all in our community. I think in terms of where the needs are, there are so many that I think people should seek to invest in the area that they're passionate about. My own personal journey to become a psychiatrist was based upon an early life family experience with an aunt who I had a special relationship with, but who then turned out to have a serious mental illness. And as I watched that unfold, I realized in retrospect, that what it evoked in me is, emotionally, a sense of compassion for this person that I love, I didn't understand what they were going through, and also a sense of wanting to understand. So I feel it was both a cognitive response and an emotional response. And so I think that for people who want to engage, they should engage in an area that meets both those things, [something] they're interested about, they want to understand it, and they care deeply about it.