Forgotten Heroes: Remembering Dr. Alvin Blount, Who Helped Integrate America’s Hospitals

http://healthaffairs.org/blog/2017/09/01/forgotten-heroes-remembering-dr-alvin-blount-who-helped-integrate-americas-hospitals/

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Mortar rounds shook the bunker. The 8225th Mobile Army Surgical Hospital (MASH) was crammed with casualties—civilians, Americans, and KATUSAs (Korean Augmentation to US Army). The four surgical tables under the direction of its acting chief surgeon, Alvin G. Blount, often operated around the clock, doing as many as 90 surgeries during sleepless protracted engagements. Blount could shut out the mayhem and focus only on his patient’s needs, as if everything else in the world had stopped. His calm, gentle demeanor commanded respect. His was the first racially integrated MASH unit, and he was its first black chief surgeon. Blount received the Korean War Service Medal for these efforts and would later become part of a group of doctors that helped radically reform US health care. He died earlier this year, the last surviving member of the group that initiated that effort.

The stories of the Korean MASH units would become popularized in a book, a movie, and a popular television series called M*A*S*H that ran from 1972 to 1983 and still appears in syndicated reruns. Yet, in an apparent attempt to assure “historical accuracy,” the television series chose to eliminate the black surgeon that appeared in the book and movie version.

After the war, Blount returned to private practice in racially segregated Greensboro, North Carolina. His Howard University medical school mentor, Charles Drew had warned him, “you boys going south will have to sweat it out, but victory will come.” Despite the US Supreme Court’s 1954 ruling in Brown v. Board of Education of Topeka that separate was inherently unequal in education, “separate but equal” remained the law of the land for hospitals. The Hill-Burton Act of 1946 specifically permitted federal funding for the construction of the two white-only hospitals in Greensboro and made similar provisions for other Southern cities. Black physicians in Greensboro were excluded from medical staff privileges at these white hospitals, one of which was the Moses H. Cone Memorial Hospital, the most well-endowed hospital in the region. Segregation in hospitals remained for another decade as Blount and a few courageous colleagues engaged in a polite and seemingly fruitless struggle against a powerful, entrenched white establishment.

George Simkins, Jr., a dentist and aggressive activist, took charge of the Greensboro chapter of the National Association for the Advancement of Colored People (NAACP) in the early 1950s and sought the help of the NAACP Legal Defense and Educational Fund (LDF) to challenge the city’s segregated hospital system. But recruiting black physicians to join as plaintiffs proved difficult. Some were comfortable with the status quo, and most were concerned about damaging ties with white colleagues, who they relied on for help with their patients. Blount himself was reluctant, but he was close friends with Simkins and knew that the segregated system resulted in lower-quality care for his patients. Blount joined the lawsuit and helped Simkins recruit five other physicians to do the same. These five physicians, in addition to two black dentists, two black patients, Blount, and Simkins, made up the final list of 11 plaintiffs. Michael Meltsner, a young, white protégé of Thurgood Marshall, served as lead attorney.

The suit, filed in US District Court in 1962, argued that Greensboro’s two white hospitals, the Moses H. Cone Memorial Hospital and the Wesley Long Hospital, functioned as an “arm of the state,” having received a total of $2.8 million in federal Hill-Burton program funds. By remaining segregated, the hospitals violated the due process and equal protection clauses of the Fifth and Fourteenth Amendments of the US Constitution. Accordingly, the plaintiffs argued, the Hill-Burton law was unconstitutional because it provided federal funding for the construction of racially segregated institutions. As is customary with any case challenging federal law, the US attorney general was given the opportunity to defend the federal government. Surprisingly, however, Attorney General Robert Kennedy joined the plaintiffs, seizing the opportunity to push the administration’s stalemated civil rights agenda. Despite this unexpected support, the District Court dismissed the suit. The “victory” that Charles Drew had promised seemed increasingly distant.

Blount and his fellow plaintiffs, however, now found themselves at the beginning of a long and unpredictable journey to transform US health care. In a 3:2 decision in 1963, the US Court of Appeals of the Fourth Circuit ruled in favor of the plaintiffs. The hospital defendants appealed to the US Supreme Court, but in a rushed ruling, just days before the Senate began its longest debate on the Civil Rights Act of 1964, the Court chose to not review the lower court decision and let it stand. Title VI of the Civil Rights Act, the most likely provision to be eliminated to assure the bill’s passage, prohibited the provision of any federal funding to organizations that discriminated on the basis of race. By letting the Fourth Circuit decision stand, the Supreme Court effectively made Title VI the law of the land before it had even passed through the legislative branch.

Resistant to any federal interference in their organization, the executive committee of the board of the Moses H. Cone Memorial Hospital recommended to the full board that the hospital return its Hill-Burton funds to the federal government to relieve it of any obligation to desegregate. That recommendation was rejected. Nothing in the Court’s decision, of course, prevented other hospitals from choosing not to apply for Hill-Burton construction funds or from returning funds they had already received. There was also no provision in the law for federal enforcement for those hospitals that had already received federal money. The NAACP LDF or other parties could mount challenges against individual hospitals, but it would be a slow and costly process.

The Medicare legislation enacted less than a year later, however, changed the game. Hospitals could survive without Hill-Burton funds, but they could not “choose” not to be Medicare and Medicaid providers. No hospital would be certified as a Medicare provider without being fully compliant with concrete nondiscrimination requirements. Local civil rights groups whose members included hospital workers served as the final arbiters. Any lapses in enforcement by federal volunteer inspectors or subterfuge by the hospitals would not escape notice.

In less than six months, 6,000 hospitals became fully compliant. Thanks to Medicare, America’s hospitals went from being our country’s most racially and economically segregated institution to our most integrated. Almost all of the separate wooden bench waiting rooms and welfare wards disappeared. Patterns of use of services that had always been shaped by racial and economic privilege began, for the first time, to reflect actual medical need. Over the next 20 years, racial and economic disparities in infant mortality and life expectancy narrowed. In Greensboro, Blount became the first black surgeon to operate at Moses H. Cone Memorial Hospital. Yet, the events that propelled all of these changes have been almost forgotten. Only current political events in North Carolina and nationally have stirred some local reflection about that past.

A statue of Simkins was unveiled on the lawn of the Guilford County Courthouse in October 2016, near where he was jailed for trespassing in 1955 after trying to play golf with friends on the city-owned golf course. Only after his death was he honored as the city’s “Moses.”

In 2016, Blount, at age 94, was the only surviving plaintiff in the Simkins v. Moses Cone Hospital suit. He was still seeing a limited number of patients under the watchful eye of his loyal long-time practice manager, Martha Reid. His office on East Market Street was filled with memorabilia and memories of more than a half century of practice. In October, he was invited to a meeting at the regional nonprofit integrated health system that Moses H. Cone Memorial Hospital became. About 250 health care professionals and community leaders attended, along with Blount’s children. Dr. James Wyatt, a black surgeon and president of the Cone Health medical and dental staff, thanked Blount “for opening doors for me.” Cone CEO, Terry Akin, addressed Dr. Blount: “It seems to me, and to our medical and dental staff, that we needed to take the opportunity to apologize for our role in this chapter of our history and to honor these individuals for challenging us to be our best selves, and for their foresight and courage in changing America.” Cone donated $250,000 to a scholarship fund honoring Blount and the other plaintiffs that will provide support for minority students pursuing careers in health care. It will be administered by the Greensboro Medical Society, one of many local black medical societies across the country that played a key role in the hospital desegregation struggle. A month later, a historical highway marker was unveiled on North Elm Street adjacent to the Moses H. Cone Memorial Hospital, acknowledging the plaintiffs and their role in changing the nation’s hospitals.

Dr. Blount passed away on January 6, 2017, at Moses H. Cone Memorial Hospital after a brief illness. His family marked his passing with a quiet event at the small Episcopal church adjoining the North Carolina A&T State University campus, which served as an early organizing center for the lunch counter sit-in movement. “My life is my memorial,” he had told his practice manager. “No big casket or cemetery plot either—cremation. … Just be sure I’m dead before you burn me.”

His life was indeed his memorial. From caring for wounded soldiers in Korea to feeding arrested Dudley High School students after a lunch counter sit-in, Blount was an endless source of compassion and integrity. He and his wife lovingly raised seven children, and his youngest daughter, Gwen Blount Adolph, now a lawyer in New York, recently reflected on her father’s life: “My daddy was a gentle soul who wanted to do right by everyone.” She recalled the night the arm fell off her brother Alvin’s teddy bear, and he was inconsolable. “We all had this vivid memory of my dad taking needle and thread and operating on Teddy…. We all gathered around, as if it was an operating room. He was so patient, and it was so important to my brother. It was as if everything else in the world had stopped—that was Daddy.”

In these divisive times, it is too easy to be dismissive of the past and despairing about the future. The lives of Dr. Blount and the other Moses Cone plaintiffs tell us something different. They tell us that landmark pieces of social policy such as Medicare, when implemented fairly and compassionately, can promote justice and equality. And they tell us that the power to remedy injustices lies with individuals who are willing to challenge the status quo and further the cause of universal health care for all Americans.

How Should We Measure The Distribution Of Health In A Population?

http://healthaffairs.org/blog/2017/03/17/how-should-we-measure-the-distribution-of-health-in-a-population/

Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Measuring population health and its distribution can unite groups across sectors around a set of clear, defined goals. However, no one metric can capture the intricate and complex nature of population health. Instead, we need a matrix of indicators to gain a full picture of health and how it is changing. (see Figure 1). For example, rather than measuring only end-of-the-line health outcomes such as mortality, we need to measure a range of metrics across the health pathway, including the determinants of health, risk factors, prevention and treatment.

In addition, to understand the distribution of health in a population and address inequalities, we need to measure health across different subpopulations.

Yet there is little evidence on which sub-population groups should be considered. Commonly used segmentations are based on socioeconomic status, geography, gender and ethnicity. However, population health can also be explored across different disease or age groups. In addition, risk factors play an important part in determining population health, and could provide a basis to segment the population. There also exist specific societal or clinical groups that carry particular relevance to policymakers, such as employees, prisoners, homeless people, disabled people or people with drug dependencies.

While all these population groups are important to population health, it is not practically possible, or desirable, to measure and present health outcomes across all possible dimensions. Therefore, we conducted an expert Delphi study, which uses several rounds of questionnaires, where the results from earlier rounds feed into the next in order to reach a consensus among participants. Our goal was to prioritize population segmentation approaches, and guide both the collection and presentation of population health data.

Implications For Policymakers

There exists a clear consensus among health care experts around the need for population segmentation in order to measure population health and health equity. However, there is no single way to do this. All ten population segmentation approaches were considered important by the panel. These results highlight the value of considering the wide range of different population groups that may influence health outcomes.

The results of this study can help researchers and policymakers prioritize the way they analyze and present population health data. In addition, these results should guide the collection of data. For example, the panel considered socioeconomic status and risk factors to be very important, but administrative datasets collect information on these issues in different ways and according to different definitions. Standardizing the collection of segmentation variables would allow population-wide analysis of the distribution of health.

Policymakers should also consider using a data-driven approach to identify population segments, rather than a priori defined population groups. Big data and data mining techniques can help quantify the distribution of outcomes in a population and identify the factors driving these differences.

It is important to note that measuring the distribution of health is only one of the many steps we can and should take to create healthier populations. We must continue to explore how population health will benefit from emerging innovations in technology, service model design and big data and analytics.

 

Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition

http://www.commonwealthfund.org/publications/fund-reports/2015/dec/aiming-higher-2015

The fourth Commonwealth Fund Scorecard on State Health System Performance tells a story that is both familiar and new. Echoing the past three State Scorecards, the 2015 edition finds extensive variation among states in people’s ability to access care when they need it, the quality of care they receive, and their likelihood of living a long and healthy life. However, this Scorecard—the first to measure the effects of the Affordable Care Act’s 2014 coverage expansions—also finds broad-based improvements. On most of the 42 indicators, more states improved than worsened.

“On most of the 42 indicators, more states improved than worsened.”

By tracking performance measures across states, this Scorecard can help policymakers, health system leaders, and the public identify opportunities and set goals for improvement. The 50 states and the District of Columbia are measured and ranked on 42 indicators grouped into five domains: access and affordability, prevention and treatment, avoidable hospital use and cost, healthy lives, and equity. Individual indicators measure things like rates of children or adults who are uninsured, hospital patients who get information about how to handle their recovery at home, hospital admissions for children with asthma, and breast and colorectal cancer deaths, among many others.

The top-ranked states are Minnesota, Vermont, Hawaii, Massachusetts, Connecticut, New Hampshire, and Rhode Island. These states were also leaders in the 2014 Scorecard.

Making The Business Case For Investing In Community Health

Making The Business Case For Investing In Community Health

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In recent years, many businesses have put a premium on improving employee health—often through investments in workplace wellness programs, onsite clinics, or the availability of fruit and vegetables on the premises.

Ostensibly, these programs are intended to generate a return on investment (ROI), with the thought that healthier employees are more productive employees, less likely to miss work, and more prepared to fulfill their potential. To date, though, research from the field has been mixed on whether workplace wellness programs and clinics deliver the ROI they promise.