feature
Working “Intentionally” to Reduce
Health Disparities
don’t think about whose specimens we
should get and who we should test. More
recently we’ve begun thinking about
how to ensure our tests are equally
available to everyone who needs them,
so we’ve started to think about access to
testing, what tests we provide and how
we provide them, to shed light on health
inequities.”
F
undamentally, the end goal
of efforts like the Utah study
is health equity, an outcome
Healthy People 2020 defines
as “the attainment of the
highest level of health for all
people.” Health equity, in turn, depends on
creating social and physical environments
that actually promote health for all.
Mighty Fine, MPH, CHES, director of the
American Public Health Association’s
Center for Public Health Practice and
Professional Development, said health
equity encompasses everything from
“who can buy homes where” to “who has
access to what healthcare options.”
In the public health
laboratory, as in public health
writ large, there is a growing
effort to ‘more consciously’
address health disparities.”
Jennifer Rakeman, PhD, New York City Public
Health Laboratory.
“Those are not arbitrary,” he said.
While health equity “is not a brand new
issue,” said Fine, “what’s changing is that
we’re unpacking it more and looking at
the social determinants of health, which is a
newer concept. In public health, we want
people to change adverse behaviors and
live a healthy lifestyle, but sometimes
people are trapped by systems that
conspire against that change. So we
have to work to identify, break down and
dismantle those systems to make change
more likely.”
Organization to declare a Public Health
Emergency of International Concern in
early 2016, after tens of thousands of
cases were confirmed in Latin America
and many more suspected.
Among the social determinants of health
tracked by Healthy People 2020—a federal
initiative that sets ten-year, national
health objectives—are the proportion of
people living in poverty, number of days of
poor air quality and homicide rate.
Fine said, “I think it’s great that public
health laboratories are engaging even
more in this space, because we know it’s
going to take a collective effort.” He called
for “thinking more strategically, thinking
about how the public health workforce
might more intentionally work with
public health labs, and how the labs can
work more intentionally with the larger
public health system.”
In New York City, an ambitious effort to
improve Zika testing two years ago shows
what can be gained by such thinking.
Zika virus—a mostly mosquito-borne
illness that can cause devastating birth
defects when women are infected during
pregnancy—prompted the World Health
PublicHealthLabs
@APHL
Zika virus
Although New York City never experi-
enced local Zika virus transmission, the
city documented 993 travel-associated
cases that year, primarily linked to the
Dominican Republic, Jamaica and
Puerto Rico.
At the time, all local Zika virus testing was
performed at the New York City Public
Health Laboratory, so authorities knew
who was getting tested.
Health department epidemiologists
noticed early on, said Rakeman, that
“the patients who were being tested were
not the patients we felt had ties to Zika-
affected areas, such as people born
in those areas and thus more likely to
travel there.”
For example, a preponderance of tested
patients had zip codes linked to the Upper
East Side, Chelsea and other affluent
neighborhoods, with far fewer from
Bronx and Brooklyn neighborhoods with
substantial populations hailing from
Latin America.
Rakeman said, historically, “Many
laboratories and many laboratorians
thought we just get the specimens and
APHL.org
Having trained at both a “well-resourced”
tertiary care hospital and a “very under-
resourced” county hospital, Rakeman
knows that it is much harder to order
tests in under-staffed facilities: “In a
ten-minute visit, spending nine minutes
trying to get a test ordered may not serve
the patient well.”
Public health laboratory staff found that
this same dynamic was playing out in the
case of Zika. Thus, in March 2016, the New
York City Department of Health launched
an “all-out effort to ensure that people
who needed Zika testing got Zika testing.”
One of the centerpieces of this effort
was a dedicated call center to provide
information to providers and clinical labs
to assure appropriate patients were being
tested and to streamline the test ordering
process itself. Call center operators used a
newly developed electronic test ordering
system, eOrder, launched specifically to
facilitate Zika testing. The public health
laboratory, in turn, received higher quality
specimen submissions, with complete
and correct test ordering data.
Additionally, the city health commissioner
held press conferences and met with
local elected officials to publicize Zika
test recommendations and the new
call center.
The result, said Rakeman, was “striking”:
“We went from a complete mismatch
[before the outreach], and after outreach
it completely flipped—the demographic
of at-risk patients matched the patients
getting tested.”
By year’s end, the city public health
laboratory will roll out an expanded
version of eOrder that will accommodate
all public health laboratory test ordering
and results rep