All my life I’ve witnessed how inequalities of race and ethnicity, gender and class pervade just about every corner of our society.   As a mother, physician, medical patient and woman of color, I’ve personally experienced up-close just how profoundly inequities in opportunity and treatment block the path for millions of us to good health, good health care and to a good life itself. 

The code word is “disparities,” which technically means “the state of being different.”  However, when it comes to health and health care, “disparities” really means that if you’re not white and if you don’t have financial resources your overall wellbeing is at higher risk and you’re going to get a measurably lower level of health care.

How to close that gap is a formidable challenge that has long evaded workable solution.  Over time I’ve confronted it professionally as a doctor, MBA, clinical researcher, policy expert and, now, as part of the country’s biggest philanthropy dedicated to solving health and health care puzzles just like this one. 

After years of extensive evidence-gathering and investment in the quality field, what is crystal clear is the direct link between the deeply-rooted inequalities in health and health care and our society’s disappointing slowness in appreciably improving the quality of care and the health status of all our people.  We cannot fix one without fixing the other. 

Part of the problem is that up to now no one has quite figured out how to connect these two pieces of the puzzle.  To change that, we must address the multiple and interlocking social, clinical and economic determinants that affect both quality and equality – causal factors like one’s personal health behaviors; whether a person has health insurance; the environments where people work, live and play; whether we have a strong, capable and diverse workforce; and whether a person is receiving the right kind of care.  The dots already are out there; now we need to connect them.  But first we must assemble the evidence. 

Pay special attention to the new March/April issue of the journalHealth Affairs. The entire issue (which RWJF sponsored) is devoted to disparities.  The findings presented here – and they are striking – reveal in specific detail from a range of important perspectives how factors such as social determinants, disparities in the health care system, and the lack of diversity in the health professions coalesce to undermine the quality and fairness of our health and health care.    

To tell the truth, I couldn’t put this issue down.  The research and commentary confirm what my own life’s experience teaches me – that health care is a human right and good health is essential for society’s survival.  Establishing once and for all a health care system that is fair and equal for all is nothing less than a moral imperative. 

Let’s not fool ourselves, though.  The job ahead is tough and it is daunting.  America’s health problems will not be solved within the clinical care system as it is currently built, nor simply by addressing health care costs or expanding coverage.

Good health comes from healthy lifestyles, good choices, and a supporting environment.  Good health care comes by delivering the right care at the right time in the right way.  Neither will occur without deep, long-lasting transformational change in our systems, in our behaviors and in ourselves.

Getting us there is my passion and the Robert Wood Johnson Foundation’s mission.  This special issue of Health Affairs certainly helps illuminate our way forward.  My hope is that others will join us on our path and help establish quality and equality for everyone in our society.   The health and well-being of all of us in America depends on it. 

I believe that the quality of health care for all Americans will not be improved without a concentrated effort to ensure that people with limited English-speaking proficiency have access to language services and assistance in clinical encounters within America’s hospitals and health systems.   In 1999, Congress asked the Institute of Medicine (IOM) to analyze disparities in our health care system, based on differences in patient race and ethnicity, which can sometimes be accompanied by language barriers. I was pleased to serve on the authors’ panel. The resulting study, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, showed that patients of different ethnicities frequently received different levels of care, even when all other factors, such as income, health status, and insurance coverage were equal. The differences in care these patients received were attributed to many different factors, including whether or not patients and providers communicated effectively.

Eight years later, nearly one in five people in the USA now speak a language other than English at home, and while most can comfortably speak English when needed, experts estimate that as many as 20 million people in America—about one in every 15 people in the USA—speak and understand little, if any, English. As America becomes increasingly multilingual, physicians and other health care providers face a tremendous challenge—one that grows greater each year: How will we communicate efficiently and cost-effectively with patients who speak or understand limited English?

Because high-quality, patient-centered health care is contingent upon patients’ understanding and following their doctors’ advice—and upon health care providers listening to and understanding the needs of their patients—the stakes for meeting this challenge could not be higher. If we are unsuccessful, the result will be even bigger gaps in the quality of care that is provided to millions of non-English-speaking patients. We will have missed the challenge called forth in the IOM report and failed ourselves as health care leaders. That is why more and more providers are trying to improve the quality of language services that they provide—because they know it is directly linked to the quality of medical care their patients receive.

Language barriers impair discussions of symptoms and recommended therapies, resulting in misdiagnoses or poor treatment decisions. Communication barriers also impede adherence to treatment regimes. Studies have shown that patients who need an interpreter but do not receive one are less likely to understand instructions for taking medications, receive less information on medication side effects, and experience lower satisfaction with their care. One survey found that, in the absence of an interpreter, Spanish-speaking patients with limited English proficiency reported significant difficulty in being able to fully explain their symptoms or trust the medical recommendations of a provider who only speaks English.

I guess this should not come as a surprise. Even for the most fluent English speakers among us, navigating a health care environment can be an overwhelming experience. Physicians, nurses, technicians, and other health care professionals typically use unfamiliar medical terminology that may sound foreign regardless of primary language. For patients who speak and understand little or no English, these challenges increase exponentially. When patients and doctors cannot talk with each other about symptoms, diagnoses, test results, medications, treatment plans, and follow-up care, the result is bad medical care.

Far too often, health care providers rely on a patient’s family member, friend, or even a member of the hospital’s non-medical staff to communicate about clinical care—yet these individuals seldom have training in translating or interpreting medical terminology. Additionally, family members or friends may be reluctant to reveal some personal information about symptoms that could be embarrassing to the patient—information that may be critical to successful diagnosis and treatment. Even seemingly simple things, like requesting an additional blanket, relaying information about a food allergy, or asking about visiting hours can seem next to impossible.

For many years, the Robert Wood Johnson Foundation has worked to improve the quality of health care for all Americans. We recognize that achieving real quality for all requires special attention to the care delivered to racially and ethnically diverse patients in hospitals and other medical settings. Among many other efforts, the Foundation’s commitment to both improving health care quality and reducing disparities in care has included:

In the coming months, the Foundation will unveil a new effort that will focus on regional strategies to improve health care quality for all. Its aim will be to help communities set and achieve ambitious goals to improve care in ways that matter to all patients and their families and, in particular, to patients from specific racial and ethnic backgrounds who often experience lower-quality care.

Eight years after the landmark IOM report on disparities in health care, I continue to believe that it will take a network of coordinated, community-based strategies to ensure that English-speaking and non-English-speaking patients alike receive the highest quality of health care available. That is something that should be automatically assumed in a country that spends more on health care than any other nation in the world. We have a long way to go, but, progress is indeed being made.

As we begin a new year, health care is center stage, spinning in a tight pas de deux with the economy as the dominant domestic issue in the 2008 presidential campaign. For the first time, every candidate for president has a real plan to improve health care and they even bicker over the details! That is the good news. So is the focus on cost, coverage and most importantly, change.   

When it comes to health care, we can all agree that change is desperately needed.  The major health problems of our time will not be solved within the clinical care system as it is currently built, nor simply by addressing health care costs or expanding coverage. We can’t afford to just throw more technology or more intensive treatment at people, nor should we have to.  More treatment isn’t the right prescription.  We need better treatment and we need less disease if we want good health for all. 

Americans have worse health outcomes than patients in other industrialized nations, even though we spend nearly three times more on health care per person.  We rank 46^th globally in average life expectancy and 42^nd in infant mortality. Race, ethnicity and income inequality affect the health of millions and the care they receive

America is founded in the pursuit of a vision, the realization of an ideal.  In words that are built into our national DNA, all of us are created equal, endowed with the inherent and inalienable right to life, liberty and the pursuit of happiness.  None of that is possible without good health. Making sure that every person in America has a fair chance for a healthy life and an equal opportunity for adequate health care is not about ideology, it’s about the future of our nation.

Unfortunately, in today’s America, when it comes to health and health care, we are not all equal, are we?  In the U.S., health disparities are enormous. Decades of expert research tells us that education, economic development, housing, job security, geography, and income all affect health just as strongly as personal behavior.  We even know now that poverty contributes to mortality of American adults at about the same rate as cigarette smoking.  Right now, there are more than 47 million people in the United States without health insurance. The uninsured not only get sicker, but their outcomes are worse. In addition to those without coverage, there are many people who only have access to poor care, but don’t even know it. 

The time has come to bridge the gap between “what we know” and “what we do.”  Here’s this doctor’s prescription for what it will take:

Collaboration is key.   Without it, the financial, clinical, professional and personal forces that frame our health and health care universe will continue to struggle with many of the same old pieces of the puzzle.  People tell us they want to be more engaged in making their own health care decisions in partnership with doctors they choose, know and trust.  They want doctors, nurses and hospitals to publicly report how they perform and they want to see solid evidence of what works best for them as patients.  They want environments that make healthy choices the easy choices.

We know how to deliver better care.   For a long time we have worked with our partners, collaborators and grantees to develop and test new ways to improve the quality of patient care at the national level. Now we are applying the lessons we’ve learned in a model group of communities of all shapes and sizes.  In these markets, we are helping local teams of doctors, nurses, hospitals, employers, insurers and patients re-align their perceived interests to bring better quality of care to the people in their own distinct regional health care marketplace. 

Improvement is key too.   People want their doctors, nurses and other health care professionals to hold “do it better” along side “do no harm” as the highest of their professional standards.  They want everyone to receive exactly the same high quality of care.  And people want their own voices heard as the community figures out how it is going to retool health care.

We must broaden our focus of what constitutes a “health issue.” Good health comes from healthy lifestyles, good choices, and a supporting environment in which to make those good decisions. While quality has long been at the top of the agenda when it comes to health care, it has only recently received attention in public health circles. As a society, we have not developed good ways to measure quality in public health practice, and we have not communicated the outcomes the public should expect from their local and state health authorities – such as immunizing all children, eliminating tobacco use and promoting regular physical activity  – to people’s daily lives. Communicating the results that public health can deliver is critical to achieving such broad societal goals.  Take childhood obesity.  We’re at risk of raising the first generation of Americans to face substantially more disability and disease than their parents. A recent New England Journal of Medicine study shows that up to 37 percent of male and 44 percent of female teenagers in the U.S. will be obese by the time they turn 35 in 2020. Federal officials already put the cost of related medical expenses and lost productivity at $117 billion per year, and researchers predict one of every five dollars spent in the future on elder care will be related to obesity. These trends must be reversed, and we need to establish performance baselines and benchmarks that will help improve public health agencies’ performance and make them accountable to the people they serve.

Change is in the air across the country and across the health and health care spectrum.  We are close to comprehensive system reform in the here and now, for the common good and for everyone in America.  This isn’t theory.  This isn’t rhetoric. This is action. The path toward improving the quality of care in the U.S. is clear, straight, and passable.  We expect success because the only ideology that counts here is the healthiest possible state of the union for all Americans. 

As we move forward together in 2008, I look forward to sharing news of programs, progress and impact.  If you haven’t already, I encourage you to visit rwjf.org , sign up for our  information updates, and join us on our exciting journey .

All of us who watch national health care costs know that the United States spends double the money per capita than any other industrialized country. One would hope that such a commitment of resources would result in the highest quality of care and the best possible health outcomes anywhere in the world. Unfortunately, it doesn’t, because more care doesn’t always mean better care.

Our country’s hefty health care bill is footed by a number of parties, with the business community paying the lion’s share for most of us. Despite dramatic increases in the number of working Americans who are uninsured, the majority of Americans are still covered by their employers’ health insurance policies. Naturally, the business community has a vested interest in getting their money’s worth and ensuring that all of their employees receive a level of quality care that companies’ significant expenditures should guarantee.

The frequency of questions about how to achieve high-quality, high-value, equitable, health care call out for national conversations about issues like performance measurement, public reporting and transparency, and I am committed to having those conversations. For decades, the Robert Wood Johnson Foundation (RWJF) has supported programs that help all of us better understand and improve the quality of care. RWJF’s efforts include funding the development of quality measures, designing early pay-for-performance scenarios, developing a new model for providing chronic care, and underwriting efforts to improve the quality of care that people with asthma, diabetes and depression receive. We have also transformed the quality of care people receive at the end of their lives.

In addition to this very useful work, however, we know that really increasing quality in health care also means ensuring equality in health care. That is why we have made a concentrated effort to identify and reduce racial and ethnic disparities in the quality of care that all patients receive.

Earlier this year, the U.S. Census Bureau announced that the country’s minority population had exceeded 100 million, meaning that approximately one in three U.S. residents are non-white. Of the 100 million people of color in America, Hispanics make up the largest segment – totaling more than 44 million or nearly 15 percent of the United States’ overall population. Blacks make up the second-largest group, totaling more than 40 million. If population rates increase as anticipated, about half of America’s population will be non-white within a relatively short period of time.

While we know that a smaller percentage of patients are white, we also know that minority patients receive poorer quality of care. A 1999 Institute of Medicine (IOM) study, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, showed that patients of different ethnicities frequently received different levels of care, even when all other factors – including income, education level, health status and insurance coverage – were equal.

With today’s rapidly changing patient demographics, health care providers cannot hope to measurably improve the quality of their care without also identifying and reducing disparities in the care that their minority patients receive. Quite simply, institutions that do not seize this challenge will fail – both in terms of patient satisfaction and the financial health of their institutions.

I firmly believe that improving health care quality will result in better clinical and fiscal outcomes. In order to ensure that health care settings are providing high-quality, high-value, efficient and effective care to all of their patients, institutions nationwide must be prepared to face and address issues surrounding gaps in quality – and racial and ethnic disparities in their care – head-on. It will require looking at quality improvement in a new light.

It will involve engaging all those who have a vested interest in the health care system – consumers, the business community, providers, government leaders, minority leaders, and others. It may involve accepting some difficult truths, identifying innovative solutions and making institutional changes that may meet resistance. Ultimately, however, it is a leap of faith that could safeguard health care institutions for the future, because patients of all races and ethnicities should expect health care that is known for its quality and equality.

America is a country founded in the pursuit of a vision, the realization of an ideal. In words that are built into our national DNA, all of us are created equal, endowed with the inherent and inalienable right to life, liberty and the pursuit of happiness.

None of that is possible without good health. Unfortunately, in today’s America, when it comes to health and health care, we are not all equal, are we?

What would the signers of the Declaration of Independence think of today’s America where your zip code determine your life expectancy, you are twice as likely to be obese if you haven’t gone to college, or your baby is more likely to die if you only have a high school education? Life isn’t just better at the top, it’s longer.

But the health of all America depends on the health of all Americans. When huge numbers of us are left behind, more of the nation’s future is left behind as well.

The problem is real. In the U.S., disparities in health are enormous. Decades of research prove that education, economic development, housing, job security, geography, and income all affect health just as strongly as personal behavior. We even know now that poverty impacts the overall death rate of American adults at about the same rate as cigarette smoking.

While much of the current public debate on health care centers on access and affordability, the evidence tells us that whether or not a person gets sick in the first place in most cases has little to do with access to care. A far greater determinant is the sometimes toxic relationship between how we live our lives and the surrounding economic, social and physical environment in which we live. Some of the factors affecting our health we certainly can influence on our own; many of the factors, however, are outside our sphere of individual control.

To this physician and philanthropist, it starts with basic questions: What kind of values do we have? Is it okay for 8 million kids to be uninsured? For thousands to die each year because the economics of health care are against them? For disparities in the health and health care of our people to weaken America’s global competitiveness? For health care costs to consume one-sixth of the nation’s economy with such great disparities in quality and equality of care?

It’s time to start seeking answers: to identify solutions that will work, partners to mobilize and actions to take that will alter the trajectory of the health and well being of the nation. All Americans would agree with Mr. Jefferson, that life is a fundamental human right. We also agree that the security of the nation’s future depends on the good health of all our people. Making sure that every person in America has a fair chance for a healthy life and an equal opportunity for adequate health care is not a matter of ideology – it’s a matter of national survival.

Flip a coin.

You stand a better chance of getting "heads" than U.S. children have of receiving high-quality health care—that is, the right care, delivered when they need it. Moreover, children get lower-quality care than adults.

This stunning news about the state of children’s health care, published this week in the New England Journal of Medicine, comes hard on the heels of President Bush’s veto of the bipartisan State Children’s Health Insurance Program (SCHIP). The SCHIP debate has focused national attention on kids’ health care coverage. That’s a good thing. More than 9 million American kids live each day without any health insurance coverage—which virtually guarantees that they’re not getting the kind of health care they need.

But the new study should put America on notice that the health care debate cannot stop at cost and coverage. What happens once you get inside the doctors’ office—the quality of the actual care you receive—is a topic ripe for discussion.

The New England Journal study, conducted by the RAND Corporation, Seattle Children’s Hospital and the University of Washington School of Medicine, and supported by the Robert Wood Johnson Foundation, is part of a groundbreaking effort to show what’s happening with our health care in America. For this latest study, researchers examined 175 quality measures for things like screening, diagnosis, treatment and follow-up care for common children’s health issues. They reviewed the medical records of 1,500 children to see how their care compared to these quality indicators. They found that, on average, children received only 46.5 percent of the indicated care. By comparison, a similar study of adults found they received recommended care 54.9 percent of the time—only slightly better, but not by much. These percentages are deplorable for a country that spends more on health care per capita than any nation on the planet.

What is this new data telling us? First, while health care coverage for children is vital, it is not enough. In the new study, nearly all of the children in the analysis had coverage, and more than 8 in 10 had private insurance—and they still received poor quality care.

Second, we’re better at treating acute medical problems than managing chronic disease. For instance, the researchers found that children receive the recommended treatment for the common cold (an acute condition) 92 percent of the time, but children with asthma received the right care just 46 percent of the time. Overall, the study found that children received the right care 68 percent of the time for acute problems, 53 percent of the time for chronic conditions, and 41 percent of the time for preventive care.

Third, some of our most pressing public health battles aren’t being fought on the front lines. Consider obesity. More than 33 percent of all children and adolescents are overweight or obese. That works out to nearly 13 million young children and teenagers. They will grow up to be among the 144 million men and women considered overweight or obese in the United States—more than half the population. Yet according to this study, only 31 percent of 3 to 6-year-olds, and 15 percent of adolescents, have their weight monitored, a critical step to forestalling later problems such as hypertension and diabetes.

Finally, the new data reaffirms something we’ve always known about health care: You get what you pay for. We have a system that has traditionally paid providers for doing things and showing up—performing procedures or conducting tests and conducting visits—but not necessarily for doing the right things, such as helping prevent or manage diabetes, asthma and other chronic illnesses.

The new study clearly shows that it is not enough to worry about covering children. We must also ask tough questions about the actual quality of care they receive. When it comes to our kids, we have to do better than a coin toss.

This year the Robert Wood Johnson Foundation committed half-a-billion dollars to fight obesity.  One of our highest priorities for the health of the American people is to reverse the epidemic’s course by 2015.

Wherever I go these days, people I meet are supportive of the goal, but not always clear on what they can do in their lives and communities.  I know that reversing the childhood obesity epidemic sounds like really heavy lifting – and it is – if you’re doing it all alone.  But you’re not.  None of us are.  It breaks down into what we each do every day, no matter the scope or scale of the task at hand.  We begin one step at a time.

To get you started, here are five practical steps.  Steps that are based on solid evidence, can deliver the desired results, and – most importantly -- you can really do them.  Taken on their own, one at a time, they don’t seem like much.  But put them together, one building on another, eventually they have the power to change the health future of an entire society.

Here, then, is Risa’s List of Five Things You Can Do Right Now.

Number One : Create a healthy food environment at school.

School is where our children spend their days learning lessons that’ll stay with them for life.  It makes no sense to teach kids well in the classroom – and then turn them loose on high-energy, low-nutrition foods and drinks the cafeteria and vending machines.

Work with your public schools to limit access to the high-calorie snacks and drinks. Provide instead unsweetened drinks and low-calorie foods rich in nutrients.  Evidence can be your best advocate.  In Philadelphia, for example, hard data convinced the city’s public schools to impose the toughest vending machine restrictions in the country.

Be a watch-dog, too.  Public schools are required to comply with the USDA guidelines for a healthy school breakfast and lunch. Maybe as many as 80 percent, however, either cannot comply – or simply don’t bother.  Steal a page from Arkansas’s book – push schools to publicly disclose details on their food and beverage contracts and revenues. With transparency comes accountability.

Number Two: Improve the availability of healthy foods at home.

Learn how the ‘food geography” of your community and state affects diet, health and obesity among both kids and adults.  Look around low-income neighborhoods.  Chances are there won’t be a good supermarket anywhere nearby.  Our research makes a direct connection between poor neighborhoods, poor access to healthy food and poor health outcomes.  We know that access to supermarkets equals availability of healthy foods. And here’s a persuasive pitch to make to local leaders: A supermarket is part of economic development.  It brings new jobs and new dollars along with healthy food.

Numbers One and Two address the Energy-In part of the equation. Three, Four and Five are all about Energy Burned.

Number Three is: Increase the level of physical activity and exercise in schools.

Only 15 percent of kids walk or bike to school.  Once they get there the chances of regular physical exercise may be little to none. The scope of what you can do here is limited only by your imagination.

► In Dougherty County, Georgia, for example, the middle schools converted some empty classrooms into fitness centers.  They’re equipped with cardio machines, weight training, aerobic classes and walking clubs.  The local YMCA provides instructors.  Teachers and principals volunteer as trainers.  So far about 200 students take part.  And their families get to work out free, too.

►  In Greensboro, Florida, the local high school is part of a state-wide fitness program called “Step Up, Florida.” Activities include three-mile hikes in a recreational forest.  The whole school, principal included, walk the track at the end of school. 

► In Evansville Indiana so many kids show up early every day at PlazaParkMiddle School that a local run-walk club organized morning walks.  About a third of the school’s 600 kids start the day walking around school grounds and corridors.  The principal reports that learning’s up, discipline problems are down, and the kids this past school year logged more than 12,000 miles walked. //

When good programs become lasting policy, culture changes.

Number Four:  Provide convenient and safe facilities where children can play.

Kids need safe, well-equipped and accessible places to play and safe ways to get there from home and back. The evidence on this is really good. A recent RAND study examined how a neighborhood’s physical characteristics affect exercise and health.  They found:

► Public safety is a public health barrier in low-income neighborhoods. Playgrounds are locked on weekends, kids stay indoors, and BMI measures are higher.  

► If there’s a park within a mile of where you live chances are you and the kids are going to regularly walk there and back.

► Having several types of businesses in a neighborhood increases resident walking trips.

Here’s where public policy can run the epidemic right off its tracks.  All the arcane stuff of local governing can be exploited to promote healthy living and physical exercise.  Urban design and land-use policies; zoning regulations and building codes; transit routing and schedules; even street lighting and crosswalk  placement; and, of course, crime prevention. Bottom line: Neighborhood design is a public health issue. 

And finally – Number Five:  Limit screen time.

On average, kids spend almost seven non-school hours eachday in front of a TV, computer, video game, DVD or listening to music. Sitting there, with no exercise at all, they’ll opt for junk food every time. I know.  I’ve been a working mom myself. The evidence suggests we have to get them early or we won’t get them at all.

► For 3^rd and 4^th graders, the NIH’s “We Can” website links teachers and parents to a school program called SMART – for Student Media Awareness to Reduce Television.  Teachers can download a year-long curriculum designed to motivate kids to cut down on TV and video games.

► For grades 6 through 8, Harvard’s Planet Health program offers classroom curricula – including a campaign to reduce screen time that’s called “Power Down.”

► In a 2-year study at 10 middle schools, Planet Health reduced the amount of time boys and girls watched television, and lowered the prevalence of obesity among girls.

By the way, the experts advise us to turn off the TV during family meal time. Research shows that families who eat together tend to eat more nutritious meals than families who eat separately.

This is a five-step starter kit.  It will get you started, but then it’s up to you.

As a mother, physician, philanthropist and woman of color, all my life I’ve witnessed how inequalities of race and ethnicity, gender and class haunt just about every corner of our society and block the path for millions of us to good health, good quality health care and to a good life itself.

The code word is “disparities,” which technically means “the state of being different.”  It really means what happens when you’re not white: that your overall health is at higher risk and that you’re not going to get the same level of health care.

Yet, I optimistically tell myself that we are making progress.  Until I attend one of those health policy conferences that draw the top researchers, health policy leaders and decision makers.  And once again, I find myself a lonely standout in a crowd of mostly male white faces.

How can America overcome inequalities and disparities in health and health care if the same experts and leaders researching the ideas, developing policy, making decisions and providing care are not as diverse as we, the American people, ourselves?

Can a room full of white middle-class professionals fully comprehend what constitutes “culturally competent” care for a low-income immigrant Latino mother struggling to raise her kids in a crime-ridden neighborhood? 

Or know what it takes to run a hospital in East Los Angeles or the South Bronx where 30 percent or more of the patients are foreign-born, speak as many as 104 different languages and present a spectrum of conditions peculiar to their own race or ethnicity or country of origin? 

The answers are obvious – those white guys can’t or haven’t or won’t.  What’s missing are ample numbers of minority experts working along with them, especially from the Latino, African-American and American Indian communities.    

Minorities may make up nearly 31 percent of our population nationally – but of all the members of Academy Health, the main organization for health services researchers and policy makers, only 1.5 percent are Hispanic and a barely perceptible 0.2 percent are Native American.  Only 3 percent of medical school and 16 percent of public health school faculties are minorities; among city and county health officers, 17 percent are minorities. 

In other words, our “insight gap” overlaps with our “diversity gap.”

As a result, researchers, government officials and health care leaders are making critical decisions affecting the lives of huge segments of America’s diverse and distinct peoples without grounding in the real-world experiences of the people and families involved.

Yes, their decision-making is informed by research and hard data.  But research without insight won’t do it; without authentic and empathetic insight we cannot accurately decode the mysteries locked within all that data and more importantly turn the research into workable solutions to improve the health of people in this country.

This tells me we have a pipeline problem: the necessary up-and-coming talent isn’t in it.  

We believe we have a way to help fill that pipeline and close both insight and disparity gaps at the same time.  We call it the RobertWoodJohnFoundationCenter for Health Policy at the University of New Mexico. The Center will be a physical, cultural and educational home for a new cadre of Hispanic and Native American health policy scholars, researchers, policy makers and leaders.  With an initial commitment of $18.5 million, the Center will be fully operational this fall.   

There is nothing quite like it anywhere in the country. However, it comes straight out of America’s tradition of successful social movements – civil rights, school desegregation, tobacco policy.  Each movement depended on the energy, passion and direction of leaders who relied on solid policy research.  So too will the future of health policy and health care in America and our new Center aims to help shape that future.

My own life’s experience teaches me that health care is a human right and good health is essential for society’s survival.  Establishing once and for all a health care system that is fair and equal for all is a moral imperative.  Eliminating disparities in care is a moral obligation.  

As we change the face of health policy leadership in the U.S. we expect health care itself to become more representative, more inclusive, more diverse.  Our hope is that others will join us in making equality an accepted fact of life in the health care of our society.  The health and well-being of everyone in America depends on it. 

Behind America’s chronic health care inadequacies is a dramatic back story of nurses fighting to improve patient care at the bedside despite a system so preoccupied with costs that nurses are shunted aside to fold linens, find lost medication and chase down doctors.

The nation’s penny-wise, pound-foolish approach flies in the face of hard evidence that nurses are essential to preventing hospital infections, reducing medication errors and keeping patients alive.

As a result, virtually every patient – and that means all of us, sooner or later – risk not receiving the medical care we need when we need it.  The consequences are serious and may even be fatal.

A definitive New England Journal of Medicine study revealed that about half of all patients do not get the care that is specifically recommended for their medical condition. The Centers for Disease Control reports that 90,000 hospital patients die from health care associated infections each year.  At least that many more die in hospitals from medical errors.      

Often, nurses are the only fail-safe professional protection patients can count on, which isn’t surprising when you consider that half of all health care providers are nurses.  Since they spend the most time with patients, they are the ones who first spot and address patients’ problems before they become critical.

Recent research reports that higher levels of hospital nurse staffing are associated with fewer adverse outcomes—as much as 25 percent fewer.  That means fewer patients with pneumonia or intestinal bleeding, fewer pressure ulcers and fewer heart attacks.  The risk of surgical patients dying within their first 30 days in the hospital improves with adequate nurse staffing.   

The vigilance of nurses may well be the most important defense any patient has against medical error. We believe much of the quality job starts and ends right here.  But too often, nurses are blocked from performing this core mission – which is what called many of them to the profession in the first place.

Instead, to save money, many hospitals divert nurses from patient care to paperwork, patient transport, running for lab results and picking up meds from the pharmacy.  This strategy is driving droves of nurses out the door – many after less than two years on the job—ironically without saving anyone any money. Short-sighted hospital cost-cutters don’t realize that the high cost of adverse events far exceeds what it costs to recruit and retain well-trained nurses.  The Institute of Medicine found that nurses are the health care professionals most likely to intercept medication errors, which cost hospitals $3.5 billion annually or prevent hospital-acquired pneumonia which can add 84 percent to the cost of that patient’s care, including nearly an extra week in the hospital. 

Nationally, nursing also should take its rightful seat at the health care improvement table with the rest of the major players – hospitals, doctors, drug companies, health plans, insurers, government.  Despite their expertise, when it comes to fixing problems, nurses are rarely asked for their opinion.

Locally, hospitals and health plans need to make sure nurses are on their boards and in their executive suites.  That’s the only way nurses will have the power to be change agents and advocates for higher quality care.

The challenge for hospitals, physicians and health care executives is to shed the old health care stereotypes of the past and recognize that nurses are absolutely essential to keeping patients safe, improving the quality of care and securing the bottom line.

Pollsters, pundits and politicians tell us that health system reform is making a political comeback,  If our leaders finally resolve third-rail issues like cost and coverage, it will be the most significant step forward for health care – and health care justice – in America in 40 years.

Without question, our health system is needlessly fractured and flawed, locked in a broken status quo by major public and private players who have lacked the will to attack the problem’s core:  That health care in this great country is unjust and unfair.

Why else would we experience huge disparities in care and outcomes between whites and non-whites; or measure rising rates of infant mortality in the Deep South; or think it’s OK that nearly 45 million are uninsured, including 9 million children?  

We’ve allowed the appalling to become the acceptable because we haven’t taken the time to connect the dots between the uninsured, the quality of care and the economics of health care.

Let’s start with some basic precepts.   

First – Health care is a human right. This is not negotiable.  

Second – Guaranteeing everyone access to affordable quality care is a moral and economic imperative.

Third – The cost of coverage is an obligation shared by the three guarantors of the great social contract that binds of all us together.

These guarantors are:

• The individual.  That’s each of us. 
  
  
• Our government – of, for and by the people.  Not the politicians, not the special interests, but all of us working together for our common good. 

• The private sector.  Securing social value is as necessary as securing shareholder value.

The only way to connect the dots of coverage, quality and economy is to keep this social contract and its three guarantors in equilibrium.  But they haven’t been in harmony for a long time.

Can we overcome such deeply entrenched injustice? 

The President said, “Of all our national resources, none is of more basic value than the health our people.”  He proposed “to provide adequate medical care to all who need it, not as charity but on the basis of payments made by the beneficiaries of the program.”

That’s what the President said, all right.  But it wasn’t President Bush or even President Clinton.  No, that was President Truman in 1947 when he asked Congress to approve universal health care coverage.

Sixty years and we’re still waiting. Meanwhile, we’ve conquered polio and small pox, unlocked mysteries of the human genome, increased life expectancy from 68 to 78 years, landed men on the moon and beamed video back from Mars. 

It occurs to me that if health care were rocket science we wouldn’t be in this mess. 

We’ll have health justice in America when we close the gaps between the haves and have-nots, cover the uninsured, deliver health care that’s color blind and improve the quality of care so everyone receives what America’s long promised – the very best health care in the world.

Unlike any other time in U.S. history, a significant number of our children and teenagers are obese or close to it – currently more than a third of them, about 25 million kids.  Most of these obese kids will become obese adults, who are likely to live sicker and die younger than their parents’ generation.     

The prevalence of childhood obesity is excessive and rapidly escalating, with severe clinical consequences.  All communities and populations are adversely affected, particularly low income communities.  Left unabated, the epidemic will overwhelm health care delivery and financing systems and destabilize health programs and other services for children, the elderly and the poor.         

To maintain a healthy weight, the energy we consume in calories must equal the amount of energy we burn. This is “energy balance.” For at least three decades we’ve been terribly out of balance—taking in enormously more energy than we burn. There is no one culprit.  Individual and family choices are driven by a mix of genetics, biology, socio-economic factors, commercial and cultural influences, and the 24/7 availability of junk foods.