By Cathy Clark
Ask someone to describe health disparities or health inequities, and the response could be inequality or difference. Someone else might describe the term as the lack of similarity of equality or inequality. Still others might suggest less positive descriptors, such as injustices, discriminations, biases, disproportions or imbalances.
Whatever the words used to describe them and wherever they may exist, health disparities are clearly and quickly recognized by Clement Gwede, PhD, MPH, RN. Gwede grew up in Zimbabwe when the south-central African nation was called Rhodesia, before the country had become independent Zimbabwe. In 1984, Gwede completed his nursing diploma program in the capital city of Harare, where he worked as a hospital staff nurse for the next two years.
"“If you look back historically, health disparities or health inequities have been here in the United States for a long time."
Gwede’s primary motivation for coming to the U.S. in 1986 was to pursue higher education. “We had only one university in Zimbabwe during the era of the early 1980s, and I wanted to continue my education in health.” He also was inspired by “the desire to identify the unjust factors that are keeping the health of some groups down.”
“I’ve always been aware of the need to create health equity, even when I was in Zimbabwe, but the dynamics are a little different in the United States,” said Gwede, senior member of Moffitt Cancer Center’s Division of Population Science. He is well aware the dynamics of and the reasons for disparities might be different among countries, but inequities — along with their adverse consequences — exist, nonetheless.
“If you look back historically, health disparities or health inequities have been here in the United States for a long time,” said Gwede.
In 1985, a U.S. Department of Health and Human Services task force released a comprehensive study of the health status of minorities, known as the Heckler Report. The report elevated minority health to the national stage and served as a driving force for changes to advance health equity at all levels of government.
Earlier, in the late 1960s, the following statement was attributed to Martin Luther King Jr., and proponents of quality health care use it frequently: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” The actual documented quote conveys what many might consider an equally strong message: “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in death.”
CHALLENGES COUPLED WITH HOPEFUL RESULTS
“For the past 50 years, we have seen a strong consciousness of the need and importance of health equities, and yet startling disparities remain,” said Gwede. “The not so good news is that they are persistent and we are not doing enough in terms of intervention and, in some cases, we still don’t know why they exist.”
U.S. death rates from all cancers combined are at least 25% higher among blacks than whites. Gwede takes prostate cancer as a case in point. “We are still trying to find whether the biology of the disease is different or if prostate cancer is a result of genetics or other influences. Is it more lifestyle, behavioral or cultural issues that we need to address? We think it is a combination,” Gwede said. “We haven’t quite hit the sweet spot, and, therefore, we are still struggling in some areas.”
Another challenge is triple-negative breast cancer, an aggressive subtype of cancer that is difficult to treat. For reasons that remain unclear, individuals of African American and Hispanic descent tend to develop triple-negative breast cancer more often than Caucasians and Asians. African American women with this subtype of cancer are known to have worse clinical outcomes than women of European descent. This indicates a need to improve access to genetic services among such high-risk individuals, and those so identified should be encouraged and meaningfully supported to undergo known and beneficial cancer prevention options.
Despite the challenges, there is good news in that much has been learned in the past few decades. “One part of the good news is that we can identify and describe the disparities. We understand quite a bit about how they have come to be, and we are committed to do something about it,” Gwede said.
“We are doing interventions to eliminate the disparities when we know the causes or sources and solutions.”
One such area of hope, opportunity and challenge involves eliminating disparities in colorectal cancer.
“Colorectal cancer is a cancer for which we have well delineated screening modalities that we know work very well. Colorectal cancer is the most preventable, most detectable and most treatable if it is found early. We have a paradigm of a cancer that we can find, remove, prevent and treat,” said Gwede. “Yet we are not achieving the elimination of colorectal cancer.”
Gwede and his colleagues are tackling the problem of health disparities, particularly in the area of colon cancer, through research, education and partnerships. It is in this area Gwede and his team have had the most achievements and where he is most professionally gratified with the accomplishments. They spend a good deal of work educating patients about the importance of screening, early detection and prevention.
“Knowledge is power, and patients and unaffected community members need to know that screening is necessary and that it is something we can easily and, for the most part, conveniently do. Not everyone has that knowledge, and the most important barrier for patients and the general public is the means and courage to get the screening done.” Anyone who has health insurance must know how and when to use it for age and risk appropriate screening. For those who are uninsured, help is often available for them to get access to the screening tests, but sometimes courage is needed as well.
80% SCREENING IS ACHIEVEDGwede and his team are focused on helping people get screened for colon cancer through the use of an easy at-home stool test, called the FIT, or fecal immunochemical test. FIT looks forhidden blood in the stool, which can be an early sign of cancer. “If the test result is abnormal, we can help navigate patients to get a colonoscopy.” A colonoscopy allows doctors to view the entire colon, identify cancer or abnormal growths or precursors of cancer (polyps), and remove them before they turn into cancer. However, this specialized and thorough test is often not readily accessible for many.Despite FIT’s simplicity and ease of use, there are barriers to overcome. “Many times we hear patients say they will not undergo screening because they feel well or are not experiencing any symptoms. Some say ‘I know my body; I can tell when something is wrong,’” said Gwede. “That is not exactly true. We think we know our bodies, but cancer often grows quietly without causing any symptoms, and by the time it causes any symptoms — whether minor bleeding or aches and pains — it may be too late.”
Gwede has led four studies in which over 80% screening was achieved for colorectal cancer, meaning that over 80% of people who received the FIT kits returned them. “From that perspective, I feel it is one of the highest accomplishments research can do when we demonstrate effectiveness.”
About 7% of people who did the FIT test had an abnormal result. Of the abnormal findings, Gwede’s team helped them to get additional testing with colonoscopy and three cancers were found. Three people had cancer of the colon or rectum, one had two additional cancers: bladder and kidney cancer.
“They all got treatment at Moffitt as a result of the simple screening; those are success stories.”
Of the four FIT studies, one was done among blacks in nonhealth care settings, such as churches, barber shops and culture centers and programs — places where the individuals who participated were not seeking health care. The other three studies were performed in collaboration with Tampa Bay area community clinics, also called federally qualified health centers. These centers provide care regardless of one’s insurance status or ability to pay.
PARTNERSHIPS SUPPORT HEALTH EQUITY
Three partnerships in particular involving Moffitt have done a great deal to address diversity and health disparities and to improve health care access to our communities.
Tampa Bay Community Cancer Network was funded by a National Institutes of Health research grant (2005-2017) to develop an academic partnership with community organizations. The collaborative network is made of local federally qualified health centers, nonprofit organizations, faith-based groups, adult education, advocacy groups, literacy groups, and Moffitt Cancer Center. The network’s unified goal is to create and implement sustainable and effective community-based interventions to impact cancer disparities in the Tampa Bay area. Since 2017, Moffitt has continued supporting the Tampa Bay Community Cancer Network, which benefits underserved communities, regardless of race or ethnicity.
Another research collaboration, the Ponce Health Sciences University – Moffitt Cancer Center partnership, is enhancing health disparities research at Moffitt, and cancer research and cancer care in southern Puerto Rico. Intended for Hispanics/Latinos in Florida and southern Puerto Rico, this research is providing more data about the behavioral aspects and genetics of cancer to know how to best improve screening, early detection, diagnosis and treatment of cancer. The partnership led to creation of a unique Hispanic/Latino Biobank, the first functional, centralized Hispanic cancer-related biobank in Puerto Rico. Representation of all groups is essential to research in preventing and treating various forms of cancer.
“I think the initial paradigm, no matter what sort of research we are doing, should always ensure equitable representation. In that way, everybody can benefit from new discoveries,” said Gwede. “What has been happening is that studies often are done with majority populations. After we find that something benefits that population, then we start asking ourselves whether it also could benefit minority groups. This incremental approach results in potentially harmful delays in which the knowledge and new discoveries are not immediately benefitting all the groups. So we are now trying to design studies upfront with adequate representation so beneficial findings can immediately translate to direct benefit for all.”
“I think there is a time to understand and address health disparities to achieve health equity; that time is now.”
Another key partnership initiative is the Moffitt Program for Outreach Wellness Education and Resources (M-POWER), under Moffitt Diversity. “Those efforts are not research fueled; they are service-fueled, and equally pivotal to bring evidence-based interventions to communities,” said Gwede. “This means that the people involved with M-POWER are going out to educate and benefit the community, and they have developed numerous partnerships to achieve what is known as best practices to promote health and provide necessary linkages to cancer care.”
The benefits of working collaboratively are evident, noted Gwede. He is pleased to say he has seen strong commitment to address cancer health disparities at Moffitt for nearly 26 years.
“The institutional prioritization and awareness for addressing cancer health disparities is tremendous including broadening charity care, by financially supporting research that addresses cancer health disparities, and through work in the cancer center’s catchment area to benefit our communities. There also has been a tremendous focus on understanding diversity within our staff, patient population and within our community, and addressing disparities with a very clear commitment of financial and leadership support,” said Gwede.
THE TIME IS NOW
Gwede’s life may look like the fulfillment of the American dream. Since coming to the U.S., he completed his bachelor’s, master’s in Public Health and doctorate degrees. After coming to work at Moffitt in 1993, he gradually rose in ranks to become a senior member, and he is a professor at the University of South Florida. His wife of 31 years, Itai, also completed nursing school in Zimbabwe. She has worked as a registered nurse for 26 years on a surgical oncology floor at Moffitt. She is now a new manager of her inpatient unit. The couple have two grown children. Their son is in medical school in Chicago and aims to become an oncologist. Their daughter completed a bachelor’s degree, works in the health and wellness field in the Tampa community, and is the mother of their first grandchild.
But Gwede is not one to sit back and rest and enjoy the good life. He is well aware that much work remains to be done, and he believes the commitment and means to achieve health equity is here.
“We are fortunate to have Moffitt leadership’s strongest commitment and support for diversity and health equity in every aspect. We have internal pilot grant mechanisms that aim to eliminate health disparities. We have transdisciplinary groups that are meeting to better understand and address disparities. There’s a prostate cancer group and others focused on health disparities research. We have a critical number of researchers that are now asking health disparities and health equity questions,” said Gwede. “We have all the momentum necessary, but clearly, not all the results. Not yet.”
So he and his team keep working during what he calls exciting times for health disparities research.
“I think there is a time to understand and address health disparities to achieve health equity; that time is now.”