The president of HRET interviews former U.S. Surgeon General David Satcher.
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| Maulik Joshi |
David Satcher, M.D., Ph.D., is the recipient of the 2009 TRUST Award from the Health Research & Educational Trust (HRET). Dr. Satcher is the director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, where he holds the Poussaint-Satcher-Cosby Chair in Mental Health. He served as the 16th surgeon general of the United States under Bill Clinton. Maulik Joshi spoke with Dr. Satcher about health care reform, health care disparities, public health interventions and leadership in a wide-ranging interview.
Dr. Joshi: How has the climate changed regarding health care reform legislation?
Dr. Satcher: I served on a task force with Hillary Clinton when we attempted to reform health care in the beginning of the Clinton administration. I think two things were done wrong. First, the proposal sent to Congress was too complex. Second, it was not a bipartisan effort. It was put forth as a Clinton health reform plan.
I think Barack Obama is taking the right approach by listening to people, including Congress. And I think he's going to have the proposal come from within Congress, not from within the White House.
Also, the imperative for health reform is much greater than it was in the early 1990s, even though it was pretty high then. Many more people are dissatisfied with the health system today, including medical practitioners and payers. There are enough people upset with the health system that I think it's going to be easier.
We have to look at the health care system as a patient who is very sick. The symptoms are uncontrollable, with runaway costs, restricted access, questionable-to-poor quality and major problems in health disparities. To respond, we have to look at the determinants of health: access to health care, genetics, biology, environment and human behavior. Unless we come up with a system that responds to all those determinants, our health care system is not going to recover.
Dr. Joshi: Regardless of specific legislation, what should health care leaders do to support health care reform?
Dr. Satcher: We should be out front working to help reform the system. We should be acknowledging that we have a real problem; we should be contributing to the solutions. For example, the need for patients to have a medical home, so we can deal with health more comprehensively, is important. We need a stronger primary care system. Hospitals are now developing primary care clinics in neighborhoods around them.
President Obama had leaders from the health care industry at his first White House meeting, and he'll have those leaders at other meetings. We need to come to the table with proposals from our perspective. We cannot do our job as well as we would like because the system is failing.
Dr. Joshi: From your background leading Meharry Medical College and now Morehouse, can you tell us how professional schools are preparing our next generation of clinicians, for example, to be more patient-centered and work better in teams?
Dr. Satcher: Physicians have to be better prepared to work as team members. Some are going to be leaders of teams, but not every physician should or will be a team leader. Regardless, they're going to have to work with a team of people providing quality health care to patients and doing it efficiently. Understanding the health team, what everyone brings to the team, and how to maximize the team's role is very important for medical education.
Second, it is important to prepare physicians to be culturally competent. We have a diverse population, and its diversity is growing. To the best of our ability, we need to prepare physicians to deal with different cultures. That gets back to the first recommendation. As we say at Morehouse, none of us can become experts in other people's culture, but we can understand enough to know that we have to have a team that has broad expertise.
Dr. Joshi: How can we accelerate eliminating health disparities and health care disparities? We've raised awareness and created tools and knowledge, but we're still struggling with "How do we make the change?"
Dr. Satcher: We have to do a better job targeting health care disparities. First, we have to reform the system so that it better responds to the health needs of different populations and different cultures. But it has to be a system that provides universal access. Over the last 10 years, we've had an increase in the uninsured in this country. We haven't had an improvement in access to care—we've had a decline. In addition, we haven't done a good job diversifying the workforce so it's sensitive and more capable of responding to the needs of different populations. And we haven't adequately dealt with other determinants—like genetics, environment and human behavior—that are so important in disparities.
There has been some attention to quality of care in some settings. But the system hasn't changed and become more public health-oriented so that we are targeting not just access to quality health care, which is important, but also targeting the environments where people live.
Take obesity, which disproportionately impacts African-Americans and Hispanics, and take children: The Action for Healthy Kids program, which I founded in 2002, targets schools because we believe schools are the great equalizers. Children come to school from all kinds of backgrounds. When children go to school, where they will spend about 1,000 hours a year, it's an opportunity to habituate them to what constitutes healthy lifestyles: regular physical activity, good nutrition, even the free meal program. What do we feed them in the free meal program? We have an opportunity to use an approach broader than just health care in trying to eliminate disparities in health—one that requires not just health care intervention but public health interventions.
Dr. Joshi: What can we do to further accelerate the adoption of known best practices, whether in public health, disparities or other issues?
Dr. Satcher: We have to invest more in translation research and intervention. There is a gap in health services research and community-based intervention research. How do we build those up? An example is the CDC's REACH program—Racial and Ethnic Approaches to Community Health—which has modeled interventions at the community level. The program funds communities, which have to be organized to receive support. They have to contract with academia or the county health department. Some programs have been very effective, virtually eliminating disparities in mammography and in the need for amputation for diabetics, for example, which means they have done a great job controlling diabetes.
We have done too little research in how we make things work in communities. So we wait and wait after we've done the research to show that it can happen. We then don't invest in programs to help make it happen. Programs of physical activity and good nutrition can reduce the onset of type 2 diabetes by more than 50 percent. But have we taken the next step? Have we invested in research to help communities implement these programs? We need to invest in translation and translation research, in health services research, and in community-based interventions.
Dr. Joshi: On topics like sexual health and behavior and mental health, do you think the current environment is more open to listening? How can we continue to address gaps in those areas?
Dr. Satcher: When we released the surgeon general's report on mental health in December 1999, it was the first surgeon general's report on mental health. It raised the issue of mental health and mental illness to a new level. We still had people questioning whether mental disorders were real and questioning whether it was fundamental to overall health and well-being. I think the report put that to rest, and it raised this issue to a level of respectability that it did not have before. The report started an effort to achieve comprehensive parity of access to mental health services.
The good news is that, when the U.S. bailout plan was passed, the Mental Health Parity Act was passed too. It didn't get a lot of publicity, but it's a major achievement. We've had to deal with a mental illness stigma that not only keeps individuals and families from seeking care but also impacts how policies are made. This act is a great step forward.
Over the next few years as the act is implemented, I think we're going to see dramatic improvement in mental health care. It comes at a critical time when many veterans—probably more than we've ever seen—are returning from the Iraq war suffering from post-traumatic stress disorders. We're seeing the highest rate of divorce that has ever existed in the armed forces population. We need to get serious about mental health care.
About responsible sexual health: We have a Center of Excellence for Sexual Health at Morehouse, which I direct. We have been running consensus panels, bringing together people who are very conservative, very liberal or moderate, to talk about sexual issues. We've had some success trying to get them to agree on some things that would be in the best interests of children. For example, we released a report in which they agreed on what should be the components of education of children about sexuality, what was an appropriate "vision for sexual health in America" and what should be our research agenda for sexual health.
In addition, we have a leadership scholars program at Morehouse. Some of the emphasis is on sexual health and disability. One person is interested in sexual health in Africa and how we get African men to take more responsibility for the AIDS problem. Hopefully, we're going to get comprehensive sexuality education in schools. I'm happy that President Obama has changed policies on grants that we make in Africa and on teaching comprehensive sexuality and not abstinence only.
Dr. Joshi: What is your advice to an aspiring researcher, practitioner or organizational leader about personally and professionally supporting the six IOM "Aims for Improvement" for health care? How can people contribute to the greater cause?
Dr. Satcher: People who aspire to help us move forward, in the health of people in this country and the health system, need to understand policy—to begin early to study health policy, how policy gets made in this country, and what it takes to change policy. There was a time when I thought all you had to do was get the science right. I learned—certainly during my time at the CDC and when I was surgeon general—you can have the science right, but to get health policy, you have to deal with the politics. You have to deal with advocacy. You have to face lobbyists who can be much better funded.
Young people interested in becoming leaders need to know how to deal with policy and translate science into policy change. The earlier people get interested, the better. People also need to know how to develop sustainable programs. We reach sustainability in three ways: (1) Build a resource base that has some lasting value rather than receive one grant after another. (2) Know how to identify and develop partnerships—they can sometimes be as valuable as money, if not more so. With the right partnerships, you can do a lot. (3) Develop a reputation for integrity and excellence. If you're going to be a leader, people need to be able to trust you and feel that you're going to do your best.
Too many young people go into a new setting and say, "I have this vision for this institution." The first question is, "What about preserving what we have?" We see people every day losing what they found when they went to an institution because they didn't focus on the question "How am I going to sustain this institution?" Once you do that, you can say, "Where are we going together?"—not just what is my vision but what is the shared vision for moving this institution. We have to be better communicators to be leaders.
Maulik Joshi, Dr.P.H., is president of HRET and senior vice president for research of the American Hospital Association. He is also a member of Health Forum's Forum Faculty Speaker Service.
HRET will honor Dr. Satcher at a reception on Thursday, July 23, in San Francisco during the AHA/Health Forum Leadership Summit.
This article 1st appeared on June 29, 2009 in HHN Magazine online site.
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