Health Equity Conversations
Raynald Samoa (Part 2)
Through Health Equity Conversations, Joshua Liao hosts a series of discussions featuring people and groups around the country working to improve equity and health through systems change.
In this episode, Josh spoke with Raynald Samoa, MD, an endocrinologist at the City of Hope and national leader in several national organizations representing the Pacific Islander community.
This is the second of two condensed parts of the conversation between Dr. Liao and Dr. Samoa, and has been edited for clarity and length. A condensed version of the first part can be found here. For full-length discussion, please access the audio recording (available episodes accessible via Apple Podcasts and Spotify).
Joshua Liao: This series of conversations is often focused around systems of how we pay for and deliver care. If we were to focus on that systems piece for a second, are there two or three areas where you think these are really key health systems changes that would really help address equity for the Pacific Islander community, be it payment, care deliver, something else?
Raynald Samoa: There’s a ton so I’ll try to be succinct. One of the things we noticed from the survey too was that there was a big delay in seeing their provider. Before the pandemic, the delay in seeing a provider kind of broke more socioeconomic lines, it was people who had higher education and made more, seemed to have less problems seeing their providers. But after, or during the pandemic, it was across the board. It was about 2/3 across all ethnic groups were having problems seeing their provider. When asked, “what was the biggest obstacle?”, one of the responses was the conversion to telehealth. And, everywhere I go, telemedicine is being touted as the answer to health equity and here I am
Raynald Samoa, MD
City of Hope
looking at data saying that that's the opposite. There’s a lot to be said about how one community perceives telemedicine, whether a phone call or video is given as much weight as a face to face visit as far as changing one’s behavior. When you’re talking about diabetes and lifestyle modification, that point is unbelievably crucial. On top of access issues as we talked about with, it is extremely frustrating.
Currently our COFA community can access health benefits but it’s very random. It depends on the administration and where they’re at, and these are communities that come from the South Pacific. They pack their family’s up to move out here, and they support the agricultural industry heavily so. Their presence here is a major benefit to this country and often times they are treated as if they’re a burden. I think that’s something we need more solid determination on, access, that goes for our immigrant populations as well. But also, our health literacy makes it difficult for communities to make sure that they have adequate access to medial services. The medical literacy goes hand in hand with our education and the fact that we have very low rates of college entrance or college completion, means that that’s going to plague us. That’s going to continue to plague us. I think for generations, we weren’t able to speak to our problems with access and our problems with health because we could not articulate it.
I’m the first Samoan that went to the University of Washington School of Medicine. I don’t want to take this lightly, I love that school. It’s the reason why I am a physician today. But it was very different being the first one there. Almost every example that had to do with where weight was a risk factor, the case was Samoan, specifically Samoan. In that situation, you start to see inequity in real time. You’re so far removed from seeing what the triggers are to the increased incidence of these conditions that what I saw providers doing was blaming lifestyle behaviors on culture and not understanding how racist that is; that the socioeconomic factors that contributed to their health inequity is not really being looked at very strongly.
There’s nothing wrong with trying to improve your cultural competency but your perspective of cultural competency should expand outside of what you perceive as their rituals around food and physical activity. It should take into account their historical presence in that community you are at. It should take into account their historical access issues and why that is. I know that is a lot to put on a provider’s desktop but I think at least having the conversations about this. I’m the interim fellowship site director here at my institution so I’m staring to see more discussion, more health equity infused into curriculums so I’m hoping that this lends itself to policy changes that will help Pacific Islanders.
JL: What I hear the loudest in what you’re saying here is that policy needs to be multidimensional so there is a facet of it that is clinical care, it needs to cascade to clinicians because that’s where health care is figured out. There needs to be an educational component, if you let people go through an educational system and then wait to address it later, you’re behind at that point. At the most distal point, there’s also these policy things that probably there are things that you don’t want to put in the hands of individuals and clinics. You want to use system redesign, and those are simultaneous, it should happen at the same time.
I’m really glad you brought up this question about telemedicine. On its face, it can do certain things, but telemedicine is not one monolithic thing. It’s different things, and even if it increases access you have to ask the question, “access to what?” So, one of the themes here is to peel back that next layer, not just say cultural competence but what is informing that competence; redesign, what is informing that? And in this case, if you think access to what, you might imagine certain modalities of telemedicine are well intended but actually create these separate and unequal tracks where you’re comfortable allowing people to use health care that might not be equitable. I think that type of framework is very useful and I appreciate you sharing that.
I want to follow-up on one other thing which I consider as part of systems and my team and I think about a lot, is this idea of trust and who is doing the communication around preventive and other care. You mentioned community health workers earlier. Is there a systems or policy approach, at least for the Pacific Islander community or others that you work with, that would be particularly promising? Because I think in different communities, people have talked about CHWs and there’s definitely energy, yet I think there’s still room to improve how we design policy around that. Not a policy prescription, but what are some early steps we can take to think about CHWs and their effectiveness in Pacific Islander or other communities?
RS: Well, definitely using them as an extension to reiterate messaging that’s done in the clinic. You talked about cultural competency, they can help translate the context of your messaging so that it has a more cultural relevant basis. When you talk about systems it’s tough because the current system is not working. I can say that because the health disparities that are experienced by NHPI are partly in result because of our system, it’s not an individual Pacific Islander that is getting sick. It is a population which means systematically it’s not working for us. I think it’s that whole understanding of what is care. As our understanding of health care and health care models, and influences of health expand, our system of delivery needs to expand with it.
The diabetes from the Western stand point is, and I’ll save you my longer spiel about it, the popular understanding about type II diabetes is that it’s a result of not eating healthy and not exercising. So, laden upon that is a lot of guilt and self-blame. We use medications to help lower blood sugars, even though the root causes of it, poor stress management, poor sleep, inadequate nutrition, and insufficient physical activity, are laden upon other stressors such as how much time we have to exercise because we work too much, having food available 24/7, and mostly calorie dense foods and being stressed all the time and not sleeping well. So, we make up for what we cannot change in someone’s real life with medications. You can see how all we’re doing is trying to put out a fire by pouring gas on it. It’s that, that structure needs to somewhat change in trying to address roots in some fashion. I know as physicians we can’t do that a lot. I try to do it, which is why I notoriously go over time, but it’s because our model is focused on getting information, examination, and prescribing. That’s why those visits are timed the way they are and reimbursed the way they are because that’s the model.
But when we talk about physician satisfaction and what will change physicians’ motivation to make changes, that medical inertia that often times plague patient outcomes, the competing demands on a physician during a visit tells us that we need to change the way the visit operates, and the resources available to the physician, to do their work. I think, currently we think about increasing reimbursement and I do think physicians are worthy of their salaries. But the salary part of the job is just one small aspect of it. If you’re going to treat chronic disease then you need to have a system that is set up to treat chronic disease from top to bottom. I just haven’t seen a lot of movement in that regard. Your paper was a nice refreshing, little take on it that, there are some models being discussed. But if we’re really going to take a stab at health equity and maintain physician satisfaction, we’re going to really have to try to explore models that look at reimbursing from a different perspective.
JL: This is my bias because this series of conversations is about recognizing the connection between what we see in communities and in health care settings as inequities, and tying it back to the system. This tension between the fact that there are certain drivers that are systems level, and yet in other ways, systems are just collective values and policies from collections of people. I think a lot of what you’re describing give a lot of that texture given your experience and I really appreciate that.
I hope that the ideas and the suggestions, and the work that I and colleagues are doing represent, one, maybe a little drop but what I hope becomes a bucket, and becomes much bigger here. I really appreciate you taking the time, Raynald Samoa, thank you for joining us today on this health equity conversation. I really enjoyed this conversation and I think a lot of the things you shared our listeners will as well.
RS: Thanks Josh, thanks for having me.