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Studies have shown that the COVID-19 pandemic is hitting some minority communities especially hard. This finding shines a light on the many disparities – or preventable differences in health outcomes among groups of people – that have existed in our country for a long time. Cleveland Clinic urologist and Executive Director of Minority Health Charles Modlin, MD, MBA, explains the many systemic factors that contribute to health disparities, and how we’re working to create a more equitable future.

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Understanding Health Disparities with Dr. Charles Modlin

Podcast Transcript

Deanna:  Hi, thanks for joining us for this episode of the Health Essentials Podcast brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc. Now studies from hotspots of the COVID-19 pandemic, including Chicago and New York are showing that African-Americans are being hospitalized with and dying from COVID-19 at a disproportionately high rate. These statistics highlight some of the health disparities that have existed in our country for a long time and specifically their impact on minority communities.

Joining us today for a conversation on this important topic is Dr. Charles Modlin. He's a practicing urologist and kidney transplant surgeon and serves as the Executive Director of Minority Health for Cleveland Clinic. He's also Founder and Director of Cleveland Clinic's Minority Men's Health Center. Hi, Dr. Modlin, thanks so much for being here.

Dr. Charles Modlin:  Thanks for having me. I really appreciate it. Thank you.

Deanna:  Please remember, this is for informational purposes only and is not intended to replace your own physician's advice. So, Dr. Modlin, if you don't mind, I was hoping we could start by defining and maybe giving some context to some of the terms that are probably going to come up in this conversation and that people might be hearing in other conversations. So maybe we can start just by explaining what is health disparity.

Dr. Charles Modlin:  Okay. So health disparities refers to a situation where a certain percentage of the population or a certain segment of the population suffers a disproportionate burden of a certain health concern and poor health outcomes. And some examples, especially in African-Americans are higher rates of hypertension compared to the majority population, higher rates of diabetes, kidney disease, a variety of cancers, heart disease. These are some examples of health disparities.

And then when you look at the African-American population, a lot of these healthcare disparities collectively contribute to the shorter life expectancy that many African-Americans have experienced compared to their white counterparts. Black men, for example, have about a six to eight shorter life expectancy than white men. And see, these are just some of the examples of the healthcare disparities and they're a variety of contributing causes of these healthcare disparities that we see.

Deanna:  Yeah. Can you talk about some of the social or economic factors that contribute to these disparities?

Dr. Charles Modlin:  Sure. So healthcare providers, policy makers, we're all becoming more aware of the existence of healthcare disparities. I remember when I was in medical school or residency internship, I don't ever remember hearing the word healthcare disparities. It wasn't really until I finished my kidney transplant fellowship, I was able to step back and take a broader view of the healthcare landscape. And I learned about an initiative. It was President Clinton's initiative, Department of Health and Human Services back in the '90s called Healthy People 2000. It was an initiative designed to nationwide eliminate healthcare disparities by the year 2000. Then President Bush had Healthy People 2010, President Obama, 2020.

Some examples of the social determinants of health or the contributing causes of these healthcare disparities of which we speak are situations in which many minorities find themselves in at no fault of their own economic despair, relates to or contributes to lack of access to quality healthcare. Many individuals don't have adequate health insurance, health coverage at all, dental insurance. And so they go without proper preventative health screenings. A lot of these individuals show up in the ER with late stage disease.

Some other examples of social determinants of health include living conditions. We all know that there's a lead problem not only in the city of Cleveland, Flint, Michigan, and other locations, many major cities actually have lead problems. And then kids who are exposed to lead have developed lead toxicity, which contributes to delayed mental abilities. Living in food deserts, lack of proper nutrition. Many people live in communities where it's not really safe to go out and walk or exercise. They may live in dangerous situations. Transportation, many African-Americans rely upon public transportation. And when we talk about the COVID-19 pandemic, that actually contributes to greater difficulty in social distancing.

The types of jobs that many minorities in particular have, do not allow them to stay home and work from home. Actually, there was some research that showed from the Department of Labor Statistics show that African-Americans, only about 20% of African-Americans have the ability to work from home compared to about 30% or more white Americans. And so these are just some of the social determinants of health. And of course, lower education rates that many minorities experience. All these collectively contribute to the social determinants of health.

And more recently, I think many of us have actually recognized this, but more recently it's become nationally recognized and acknowledged that race and racism itself actually contributes to the social determinants and public health outcomes exhibited by minority population. So those are some of the examples and as healthcare providers, I think it's important that we recognize these examples and intervene in any way possible to reduce the social determinants of health and these healthcare disparities.

Deanna:  Absolutely. So when we talk about achieving health equity, what does that mean?

Dr. Charles Modlin:

So basically, achieving health equity means that we want all populations, all patient populations, communities to have basically equitable access to healthcare opportunities, to opportunities to improve their health outcomes, opportunities to undergo routine preventative health exams, access to dental health. A lot of these conditions, diabetes, hypertension, heart disease, kidney disease, and even many cancers can be present in any given individual. And that individual may not actually have any signs or symptoms until the late stages. So basically it just refers to the fact that everybody actually should have equal access to healthcare so that they can maximize their health outcomes.

That includes also access to health literacy education. So individuals will understand the importance of undergoing preventative health screenings. One such example is African-American males, the national recommendations from the American Neurological Association dictate that African-American males should start screening for prostate cancer at the age of 40, whereas white males, unless they have a strong family history, don't have to start screening until age 55. That's an example of health literacy. Many men of color don't know that they need to start screening for prostate cancer earlier. In fact, many healthcare providers don't know that as well. And so it's important that we educate the community and healthcare providers about ways in which we can achieve health equity.

Deanna:  And can you share a little bit about what we know about how COVID-19 specifically is affecting our minority populations?

Dr. Charles Modlin:  Yeah. So initially, and this is unfortunate that the CDC public health departments did not in many instances when they were screening individuals for COVID not include the individual's race or ethnicity on the data collection form. And so for a while, we thought maybe that African-Americans and other minorities did not contract COVID at as higher rates as the majority population. But later on, when we saw the data on race and ethnicity and even zip codes, it was demonstrated clearly that African-Americans in particular, other minority too, or lesser extent, but especially African-Americans had a greater incidence of contracting or acquiring the COVID-19, coronavirus infection, but also had greater morbidity, greater percentages of hospitalization and ultimately greater higher death rates.

In the city of Chicago, which I think was the first city that reported on this data, this race-based data demonstrated that in Chicago, the population in Chicago was about 30% African-Americans yet about 72% of all those individuals who were dying from the coronavirus were African-American. That is a huge disparity. Nationwide now these statistics show that about 20,000 African-Americans have actually died from COVID-19. That is a remarkable disparity. It represents about 50 out of every 100,000 African-Americans are dying from COVID. Whereas you look at the white population about 20 per 100,000, Hispanic, Latino populations, Asian-Americans are about 23 per 100,000. So you can see that as a remarkable disparity in terms of the incidence and the death rates from COVID.

Now we're starting to understand why that is occurring. And it's believed to be because African-Americans have a greater incidence of preexisting conditions, a greater incidence of health disparities that we've spoken about diabetes, hypertension. Some of these conditions actually result in lowering the individuals innate or resting the immune system. And thereby that predisposes these populations to greater susceptibility, not only to the coronavirus, but also influenza and other infectious diseases.

So also there is evidence that once African-Americans are infected with a coronavirus, they have a disproportionate or a higher immune response once infected and that results in tissue damage, not only in the lungs, but other parts of the body, the kidneys and other places. And that's why it's been observed that oftentimes African-Americans who go into ICUs, get put on respirators, ventilators are more likely are to succumb, die perish from the coronavirus. So it's believed to be related to the existence of preexisting conditions and healthcare disparities, poor nutrition states, and some of these other healthcare disparities that we talked about that predisposes these minority populations to more susceptibility and a greater death rate from the coronavirus.

Deanna:  Yeah. And you alluded to this a little earlier, but is access to testing or treatment also an issue here?

Dr. Charles Modlin:  So initially access to testing was a component. I think there was a greater, or there was actually less access that minority communities had with respect to testing nationwide. Many testing centers and most testing centers require a physician's order for an individual to actually acquire the test or to have an opportunity to get tested. Also, many of the testing centers required the individual to be able to drive up to a testing facility. Again, many African-Americans and others may not have an automobile, a vehicle to get to the testing center. A lot of the testing centers were not necessarily located in minority communities that were easily accessible.

And the other thing is that many minorities were not necessarily aware of what some of the symptoms of the coronavirus, the COVID-19 may be. And so many individuals may not have recognized that they needed to be tested. So that is a very valid point. Actually Governor Mike DeWine actually has indicated that anybody or in his wish executive order that anybody who wishes to be tested for the coronavirus should be tested. But that doesn't necessarily mean that every hospital or testing facility has enough testing kits or enough individuals to perform the testing that everybody who wants a test regardless of symptoms can get tested. So that's one of the things that we're working towards so that everybody who wants or needs a test can get tested.

Initially, individuals who were asymptomatic did not fit the criteria for those to be tested. But now we're trying to expand that. So yeah, access to testing has been an impediment. It's something that we're working to promote and increase testing locations. Here in Northeast Ohio, we're working with the different hospital systems, we're working with different government agencies and other community organizations including the clergy to provide additional testing centers for everybody.

Deanna:  I've heard you talk before about the importance of culturally sensitive communication and how some of the universal advice that we've been hearing about ways to prevent COVID-19 doesn't necessarily take into account some of the nuances in our minority communities. And can you talk a little bit more about what you mean by that?

Dr. Charles Modlin:  So, yeah, that is very important. The importance of cultural sensitivity, cultural competency, trying to understand what unconscious biases or implicit biases that we all as healthcare providers may have. It's very important. Actually research has shown that cultural competency and communication between patients and caregivers is very important in terms of establishing a rapport or a trusting relationship that's going to lead to improve health outcomes, better compliance on the part of the patient. Many patients, not all minorities, I'm not suggesting that at all, but many minorities actually prefer to have a racially concordance relationship with a physician from the same race or ethnicity to lead to better communication, a better trust.

That's one of the things that we recognized early on here at Cleveland Clinic with respect to the COVID-19 crisis. We've all seen on TV, many public service announcements talking about the importance of mitigation strategies to prevent or reduce the spread of COVID, cough etiquette, wearing a mask in public, social distancing. I talked about many situations where it's more difficult for minorities to social distance, transportation issues. Many individuals live in crowded living conditions are not afforded the opportunity to work from home.

And in recognizing this and the social determinants of health, a group of black physicians at Cleveland Clinic, probably about 16 of us, we could have actually gotten many more, but a group of us got together and produced a public service announcement video, and also an audio version. And the reason we did that was specifically to try to relate, try to engage better using black doctors to better engage minority African-American populations about what is the important information they need to know about COVID and specifically also to educate them and inform them, why is it that African-Americans are more likely to get COVID and die from COVID.

And in our public service announcement, we also explain to the individuals why it's important and what they can do to avoid contracting COVID and protect themselves and their families. You know individuals, all individuals, regardless of race or ethnicity, when interacting, when healthcare providers interact with them, they want to understand why is it that they need to follow a certain treatment regime or recommendation. And by producing this public service announcement that the black doctors got together to try to explain to the community why it is especially important for African-Americans, other minorities to social distance and use these mitigation strategies to the best of their ability.

Deanna:  So you mentioned some other conditions where we also see disparities. Can you highlight a couple of those that are kind of top of mind for you right now beyond COVID-19?

Dr. Charles Modlin:  So beyond COVID-19, we see disparities with respect to infant mortality nationwide, and it's especially prevalent in Coyote County. That's something Cleveland Clinic is engaged to try to look into, to see how we can mitigate that. We see a higher incidence of other respiratory diseases, higher incidents of lung cancer, late stage presentation of many of these conditions, a higher incidence of colorectal cancer. But again, many of these symptoms, you don't have to have any signs or symptoms to exhibit. We see higher rates of diabetes in some instances, in some locations, African-Americans have about an 80% higher ends of diabetes. Nationwide we have about a 40%, anywhere between a 35 and a 40% incidence of high blood pressure in black populations. The national average only has about a 20 to 25% incidence of hypertension, high blood pressure, and a higher incidence of glaucoma, stress, anxiety, and depression. I mean, the list goes on and on.

And higher incidence of stroke, re-stroke. In 2019, for example, we established our Cleveland Clinic Neurological Institute Minority Stroke Center to address a lot of the disparities that we see in the incidence of stroke, stroke recurrence, higher morbidity, mortality from stroke. We recognize actually there's a higher incidence of Alzheimer's disease in the black population as well. So actually what we're doing to combat a lot of these health disparities, and again, they're prevalent throughout the spectrum, all the different specialties of medicine, we're establishing what we call a multicultural health center of excellence, which is basically establishing health equity programs in every institute, every department to address a lot of the health disparities that are seen in all these different specialty areas.

One of the things that I always stress is that everyone should actually establish care with a primary care provider. Every child should have a pediatrician to perform routine preventative health screening so that we can actually prevent conditions or treat conditions in early stages so that we don't actually have to see a lot of these healthcare disparities that we see. So there are a lot of things that we're trying to do. There are a lot of health disparities that now the nation is recognizing. And so we all need to come together to eliminate these healthcare disparities.

Deanna:  So when we talk about addressing and eliminating these disparities, have there been examples of strategies that we know have worked in certain areas, or how are we going about approaching that?

Dr. Charles Modlin:

Sure. Well, one program that I'm proud of, we started back in 2003, several years even before that leading up to establish our annual Minority Men's Health Fair. And this is an opportunity. And again, we did this, it's a men's event because as urologist, our initial target disease was eliminating disparities in prostate cancer, but the Minority Men's Health Fair is an opportunity for men of color. But actually of course, at Cleveland Clinic, we welcome all patients regardless of race or ethnicity, but we target men of color because of the higher incidence of prostate cancer, other conditions, opportunity for these individuals to come in for free preventative health screenings, health examinations, health education.

The first year of 2003, we had about 35 men show up to the health fair. I thought that was actually a great number. Now, 18 years later, we've had each year 1,500 to 2,000 men. Now we have set four simultaneous locations in Northeast Ohio. We have about 650 volunteers, Cleveland Clinic caregivers, and other caregivers, community organizations coming together to provide these free preventative health screenings in the health fair. So this is a very successful program. I think it's, I call it the best practice example of what we can do to perform community outreach. I call it community outreach for community in-reach.

Our goal is to establish long-term relationships with members of the community. Not only to engage them for one day during a health fair, but to engage them for their lifespans for preventative health care. So we can establish a long-term relationship with an internist, a family practitioner, a specialist as needed. I say, every man should have an urologist also. Urologists are specialists who deal with diseases of the male reproductive system, the urinary tract, the kidneys, and we work in concert and collaboration with our primary care partners.

So our Minority Men's Health Fair or Minority Men's Health Center, which was established in 2004. That's a best practice. That's a very successful program where we're available year-round for these men to come in, to be seen, to undergo preventative healthcare, urologic care, internal medicine, primary care. These are just some examples. Cleveland Clinic has a number of other programs led by our Office of Diversity Inclusion, our Community Relations Department, our Functional Medicine Department. So we're doing a lot here at Cleveland Clinic to address a lot of these healthcare disparities. We can't do this in isolation. It requires collaboration, teamwork and partnership with outside organizations.

Deanna:  And what are some of those outside organizations, or maybe not specifically organizations, but other parts of our society that need to be involved in solving these problems?

Dr. Charles Modlin:  Yeah, so we've been very successful in our ability to engage, especially, African-American men and men of color for our health fair and Minority Men's Health Center. And that actually in of itself that is very unique. Not every health system has been able to do this to effectively engage these individuals. So you have to 2,000 men coming in, lining up to get prostate exams. It's almost unheard of. And the way in which we've had success is through our partnership with credible organizations, it requires actually developing trust within the community. And that trust has been facilitated by partnering with, for example, the United Pastors in Mission, which is a group of a number of churches, several hundred churches that come together and they endorse what we're doing. They encourage men to come in to get the screenings.

And by the way, I mean, there are a number of women who are referred to my office and Dr. Linda Bradley and others at Cleveland Clinic, and we facilitate improved healthcare access and screenings for women as well. The Urban League, the 100 Black Men, National Kidney Foundation, The Gathering Place, there were other churches, clergy, that are involved. City Councilman Blaine Griffin, Councilman Kevin Conwell, Basheer Jones. I mean, a number of individuals have come together in partnership. And we have, again, like I said, we have volunteers from the Cleveland Council of Black Nurses, the Black Professional Association, and we have 650 Cleveland Clinic volunteers and others coming together to make our health fair the success that is become.

Again, it's realization that we can't do this in isolation. Our numbers grew for our health fair after we realized that also in the black community, not in all situations, but in many, a lot of times it's the women who are making a lot of the healthcare decisions for the families. And so we actually went out and got an audience with a lot of the women, different sororities and other organizations to educate them about what they need to know about black men's health. And a lot of the men that come to the health fair come by the I'm not going to say coercion, but I mean, they come at the urging of a lot of the women out there. So we owe a debt of gratitude to the women out there for helping improve and save the lives of a lot of the black men.

Deanna:  How do we measure disparity and know that we're really moving the needle?

Dr. Charles Modlin:  So it's a long-term process. It's nothing that we're going to necessarily see overnight. We're not necessarily going to end disparities overnight. It's a long-term process. As I said, I think success is measured also by our ability to engage a certain population that we're trying to engage black men, especially who have the highest incidence of the healthcare disparities of which we've been speaking. So a lot of times, we can get men to come in, other individuals to come in undergo screenings, provide them with health literacy education. Oftentimes we're never going to know exactly what impact we've had on these individuals. They may come and learn about stroke prevention, prostate cancer, or the importance of undergoing a colonoscopy to screen for colorectal cancer. We're not going to necessarily know that they take action immediately. They may actually decide to take action, could be several months, several, several years down the road.

We actually have done market research through our, in collaboration with our Corporate Communications department here at Cleveland Clinic. And we see every year a number of individuals who have never been Cleveland Clinic patients, after they come to the health fair, for example, they registered to become long-term Cleveland Clinic patients, whether being seen in primary care, urology or other departments. That is one way in which we can measure it.

Other ways that we measure it when we access these patients, for example, patients with diabetes, we can measure a blood test. It's called the Hemoglobin A1c. And over a period of time, we can see that that is improving. Hemoglobin A1c is a measurement of long-term glucose or blood sugar control. We can follow patients, their blood pressure, for example. Our primary care colleagues have different metrics that they use to measure the effectiveness of our outreach and our care. We call it value-based care.

And so the percentage of hypertension control diabetes control, we can look at the BMI, weight management. There are number of things we look at to measure our effectiveness in terms of the community engagement outreach. But overall, again, it's something that is going to require persistence, determination. We have to stay with it and continue to develop our programs, continue to perform outreach, to engage the community as to why this is all important. We also need to target young kids, our youth, because we're seeing a higher incidence of diabetes, hypertension, kidney disease in our youth. So we needed to target them. And also we can't forget about the importance of including in the equation, the importance of mental health, assessing individuals, an individual's mental health status, their stress level anxiety, because mental health stress, anxiety, depression actually can translate into physical manifestation of certain diseases.

So we have to look at the whole patient. We have to try to understand and question them, what are their living conditions so we can assess the social determinants of health that may be impacting them. And these are the things that we need to do. So it's not always possible to immediately measure our impact, our impact in terms of reducing health disparities, but we have to stick with it. The first step is actually to be able to understand that these disparities exist, that these social determinants of health translate into poor health outcomes. And then we actually have to be effective in engaging these populations. So it's a multi-step process, but we know what works and we just have to stick with it and continue to do what we know we need to do.

Deanna:  Absolutely. So as we wrap up, is there one final takeaway message or a call to action that you want to leave our listeners with, maybe who now are coming to understand these issues and really want to participate in the change?

Dr. Charles Modlin:  Well, first of all, I'd like to say that I'm very proud of our caregivers, our leadership here at Cleveland Clinic, who understand the importance of addressing these health care disparities. Our CEO, Dr. Tom Mihaljevic is very supportive. Dr. Cosgrove, our former CEO. Dr. Mihaljevic actually recently recognized as did Cleveland City Council, that race and racism play a role in terms of the lower public health outcomes exhibited in African-American and other minority populations. So I'm very proud of also the volunteers here at Cleveland Clinic who have stepped up. I'm proud that there are many like-minded individuals who want to eliminate health disparities. As I said, we're developing these health equity programs, these centers of excellence throughout our enterprise and all the different institutes and departments.

I also would like to leave with the audience that one does not have to have an MD degree, a DO degree, or RN degree, a nursing degree to be a healthcare provider. Cleveland Clinic actually recognized years ago that every employee of Cleveland Clinic is actually a caregiver, a healthcare provider. All it takes is for us to disseminate important information. In some instances, it may be lifesaving when people understand, or if we tell somebody that, hey, you need to go in and get your colonoscopy. You need to go and get your prostate checked. You need to go get your blood pressure check. You need to know what your kidney score is to determine whether or not you have any preexisting kidney disease that could be prevented by a health check.

So we're all healthcare providers. You don't have to go to a medical school or nursing school for that. Together, we can actually realize an end to these healthcare disparities. Together, we can actually make a difference in combating these social determinants of health. Together, we can end racism that actually contributes to the health disparities that we've discussed.

We need to partner with corporate communications, or media affiliates, and collaborators. I appreciate the opportunity to have been interviewed. Your attention to this story is actually going to translate into saving lives. We're never going to know exactly what impact it has, but I can assure you individuals are going to see this program, this interview understand about this topic. Individuals who have never been exposed or were not aware of what we're talking about today. So there are a number of things we can do together. And I really appreciate having had the opportunity to be on the program, discuss these important topics.

Deanna:  Well, thank you so much. We really appreciate having you as well. And if you all would like to learn more about the Minority Men's Health Center, visit clevelandclinic.org/mmhc. You can also find more podcasts with our Cleveland Clinic experts at clevelandclinic.org/hepodcast or wherever you get your podcasts. You can also follow @ClevelandClinic on Facebook, Twitter, or Instagram for more health tips, news and information. Thanks for tuning in.

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