One Doctor’s Quest to Demolish Health Care’s Racist Barriers

In 2005, Marcella Alsan earned a master’s in public health from Harvard. Before heading back to school to earn her medical degree, she went Tijuana, Mexico, to tutor at an orphanage for a year. She ended up providing physical therapy to a young boy with hydrocephalus, a condition where fluid builds up in the brain. They would move him off the floor, try to swing his legs and arms, and sing to him. The boy had previously been unable to obtain a shunt while a baby that would have helped relieve fluid buildup. As a result, he was now suffering from brain damage that left him bedridden.

“The contrast at the border was so incredibly stark,” Alsan told The Daily Beast. “I think it motivated some of my work on health inequality.”

Years later in late 2021, Alsan, now a professor of public policy at Harvard, would be recognized for her timely research on how the legacies of discrimination had perpetuated racial disparities in health care and health outcomes in ways we are only now starting to see discussed in the public forum. She was among 25 Americans selected for the very prestigious MacArthur Fellowship, which awards people $625,000 over the course of five years to pursue creative endeavors and influential work that is geared toward “building a more just, verdant, and peaceful world.”

Alsan’s work these days is in analyzing health-care trends through the lens of what she calls “the economics of the downtrodden.” It’s quite a unique landing point for someone who used to work as a practicing physician, and who later on pivoted into economics.

After getting her master’s from Harvard, Alsan first hoped to work with Doctors Without Borders, as she had “always wanted to work on health care for indigent populations,” she recalled. But her experience on the ground instigated her to look at the economics of health care. When she visited Ecuador in 2004, she noticed a shortage of insulin due to cutbacks on health and education budgets.

“What motivated me [to pursue economics] is thinking about poverty and the root causes of unequal distribution of disease and medicine.”

She tackled her dual passions concurrently, securing her PhD in economics at Harvard in 2012, and earning an Infectious Disease Fellowship at Mass General Brigham in 2013. The fellowship in particular aims to train leaders in the field of infectious diseases who ensure diversity, equity and inclusion remain on the front burner of their careers.

Her research has moved her from simply studying the effects of health-care disparities, to more aggressively seeking solutions. Black men, for instance, have one of the lowest life expectancies of any major demographic group in the U.S. In her well-known 2019 paper published in the American Economic Review, Alsan and her research team outline a double-blind study they ran in Oakland, California, to test out one strategy to reverse this disparity.

In Oakland, the team opened up a pop-up health clinic, recruiting Black men from nearby barber shops to be patients and hiring 14 doctors, half of them Black, half of them white. Patients were randomly assigned to each doctor for individual consultations every Saturday in an experiment that lasted 11 weeks. The researchers observed the extent to which patients advocated for their own preventative care, such as checking their blood pressure or getting a flu shot.

The study found that Black patients were much more likely to opt for every preventative service available, particularly invasive services such as drawing blood for cholesterol readings, after meeting with a doctor. Alsan also concluded that consultation from a trusted medical source could possibly increase life expectancy for a Black man by as much as 1.5 years.

“While I wasn’t completely shocked by the results, it was pretty surprising to me just how unambiguous they were,” said Alsan. Unfortunately, Black Americans make up 13 percent of the U.S. population, but only 4 percent of all U.S. physicians.

“We have to increase opportunities for people from non-traditional and low-income backgrounds,” said Alsan. “Medical school is very expensive. and the application process requires many steps and mandatory courses. We could lower the cost of tuition and provide much more advising and coursework for people who might not have had exposure to these careers.”

Alex Ortega, the director of the Center for Population Health and Community Impact at Drexel University, lauded the 2019 study results. He told The Daily Beast Alsan’s work echoes similar research he’s read on “how care improved when minority populations were matched with providers of the same race.”

But he would like this issue to be addressed beyond simply diversifying the health-care workforce. “More needs to be done to bring equity into health care,” he said, “and we need major reform in health care to make that happen.”

Seeing that inequity play out in another area of health care research is core to one of Alsan’s next projects. “Historically Black patients have been underrepresented in clinical trials, either compared to the U.S. population or the burden of disease,” said Alsan. In a working paper that has yet to be circulated, Alsan and a team of others from Stanford and Harvard studied how doctors interpret clinical trials for medications that vary in the share of Black patients enrolled.

They found that the more doctors see Black patients enrolled in these trials, “the more responsive they are in terms of being willing to prescribe that medication to their patients,” said Alsan.

Visiting a doctor of the same race has an enormous impact on health-care treatment for Black patients. As noted by Ryan Huerto, a family physician and lecturer at the University of Michigan, “Mounting evidence suggests when physicians and patients share the same race or ethnicity, this improves time spent together, medication adherence, shared decision-making, wait times for treatment, cholesterol screening, patient understanding of cancer risk, and patient perceptions of treatment decisions.”

Running parallel to this conclusion was another intriguing result: When Black patients were exposed to a drug trial that had a more representative share of Black participants, they viewed the drug more favourably than if there were very few Black participants. That means they could potentially be less skeptical about how that drug may work for them. When you see yourself represented in health care, you don’t feel on the outside looking in, wondering if a medication will actually work for someone of your background. “Representation in the trial definitely influences how patients perceive the efficacy of a drug,” said Alsan.

Her other project, the details of which have yet to be finalized, will focus on health care in U.S. prisons. “I’ll be looking to understand the challenges associated with providing health care in our nation’s jails,” she said, “as well as how we can bring about an improved quality of health care there. Because there isn’t a lot of oversight on the level of care in these institutions.”

Inmates are often sicker than age-matched controls, with higher rates of diabetes, hypertension, asthma, and HIV, Aslan noted. In a 2009 study, around 44 percent of jail inmates reported having or once having cancer, hypertension, heart disease, kidney disease, liver disease, or other chronic conditions—compared to 27 percent of the general population. Alsan, along with Harvard law professor Crystal Young, want to investigate how these disparities are occurring, and where the role of race and ethnicity situate in administering health care to jailed patients.

In the wake of new efforts to reverse racial and wealth disparities in public health, Alsan’s work has earned a particularly bright spotlight. Laura Scholl, the senior program officer for fellows at the MacArthur Foundation, told The Daily Beast Alsan was picked for the fellowship in great part because of her goal “to improve health outcomes for historically marginalized and mistreated populations. She is quantifying the need to diversify the medical profession in the starkest terms and demonstrating that physician workforce diversity is a key component of achieving better health outcomes for people of color.”

But can researchers like Alsan effectively study those disparities in health care interactions delivered by online video? Alsan’s research targets in-person patient-doctor relationships. But the rise of telehealth, especially after the COVID-19 pandemic, means a greater number of people are meeting with their doctors remotely. In a 2021 global consumer survey from digital testing firm Applause, 63 percent of respondents who had used telehealth in the past plan to boost their use of such services even after the pandemic ends.

How does Alsan view the rise of telehealth and virtual physician visits? “What keeps me up at night,” she said “is that early adopters—meaning those who can afford it—will enjoy this exciting technology. The opportunities for equity are profound, since telemedicine means cutting down on transportation and parking fees a patient can incur.

“But,” she said, “what about those who can’t afford these services? This is trending to be an elite service, and I hope that will be addressed at some point.”

When Alsan looked back at early signs she would dive into health care work focused on racial and economic disparities, she remembered a song her mother used to sing to her as a child: “We are made for service, to care for each other. We are made to love each sister and brother.”

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