Primary care, private practice: A dedicated physician tackles zip code related health disparities.

Cleveland, Ohio native Carla Harwell, MD has had “boots on the ground” working to eliminate health disparities in the Cleveland area for many years. As an African American setting up a primary care private practice in an underserved location, Carla was very conscious that zip codes often define health and determine life expectancy, along with other social determinants. She set out to do something about this reality by providing a local alternative to clinics and hospitals, taking a 360-degree view of her patients, and encouraging patients to keep moving. With Bonnie Mason, MD.

Episode Transcription

Primary care, private practice: A dedicated physician tackles zip code related health disparities.
Featuring Carla Harwell, MD.

[Recorded March 2019]

Bonnie: Hello, you are listening to the Health Disparities Podcast from Movement Is Life. Conversations about health disparities with people who are working to eliminate them. I am Dr. Bonnie Simpson Mason, founder and executive director of Nth Dimensions and an orthopedic surgeon. Today, I am discussing health disparities and your zip code with Dr. Carla Harwell from University Hospitals, the Otis Moss, Jr. Health Center in Cleveland, Ohio. Welcome Dr. Harwell. Thanks so much for being here today.

Carla: Thank you. Thank you for having me.

Bonnie: Absolutely. It is really an honor to be here with someone, quite literally, you have had boots on the ground, working to combat health disparities, I mean for years. The work you’ve done over time has really had an impact in your particular community. I suppose that’s why you’ve chosen zip codes as really, one of the impassioned areas that we will discuss today. But, you know, tell us what lead you to a) primary care, but to this particular mission, when it comes to the people you serve in your zip code.

Carla: So, having grown up in Cleveland, I don’t recall really, going to the doctor. I really don’t. My first recollection of physicians were tall, white men in white coats. So, the neighborhood that I lived in we lived, actually, right across the street from the hospital that my mom worked at, and, back in the day, there was no such thing as latchkey kids. So, when my sister and I got out of school, which was also right across the street from the hospital, we would cross this busy street to go to work and sit with my mom until she got off work. So, I was five years old and so that was my first experience of looking around this hospital and seeing all these white men in these white coats and having had no prior, real memory of myself going to a doctor, I asked my mom, I said, “What do those guys do? What do those guys in those white coats, what do they do?” She said, “Well, these are doctors. They take care of people. They make people well. They help sick people feel better.” I said, “Oh, that’s what I want to do. I want to do that when I grow up.” And, of course, moms being moms said, “Well, you can be whatever you want in this world.” And so, from that young age on, I always said I wanted to be a physician. I never strayed from that. Developed a love and passion for the sciences and never wavered from wanting to be a physician. And that lead me to undergrad and med school, and then, it was ultimately, my goal to come back home to Cleveland and practice medicine in an area that had not seen primary, at least in a private practice based model of care, in a long time. You know, in the African American community, sometimes, just the word clinic, itself, has very negative connotations. It means substandard care, substandard doctors. I’m going to see a different doctor every time I go. It’s just like the Greyhound Bus Station. Just another name and number waiting to be called.

Bonnie: No continuity.

Carla: No continuity. And so, it was my goal and aspiration to go back to an area of Cleveland and practice medicine and serve an underserved community and give them that sense of I am your primary care doctor.

Bonnie: And I care about you.

Carla: And I care about you.

Bonnie: And I care about you. You know that’s interesting because we know that 70% of minority populations are taken care of by minority physicians or physicians from underrepresented backgrounds. I think you just really, hit the nail on the head with one of the core reasons why so many minority physicians do so. I mean, because, you tell me, at five, the fact that you all lived across the street from a major healthcare institution that you may or may not have had access to in order to obtain your own healthcare. Am I right?

Carla: Right, right and this still happens today. You can live within walking distance of getting good healthcare, but do you really, have access to it? And that leads me to this whole zip code thing. Why should where I live determine how long I live. There’s data out there that shows that your zip code determines your life expectancy and the zip code that my practice is in has a life expectancy of 72 years old. Now, I’m fortunate enough to live in one of the suburbs of Cleveland. And, where I live, the life expectancy is 80. Now, I don’t live that far from where I work, yet there’s an eight-year age difference in life expectancy.

Bonnie: Just by virtue of zip code.

Carla: By virtue of your zip code. So, one has to ask the question, why? Why is that? You know? And that also is part of my passion of, not only just delivering primary care. Not just taking care of patients’ blood pressure and diabetes and all the other diseases that are prevalent in the patient population that I serve, but you have to look at the big picture. You have to look at the zip code that you live in and why your life expectancy is less. And then, that opens a much broader Pandora box because it might be access to care and it doesn’t matter that you live right there. What if you don’t have any insurance?

Bonnie: You can’t pay for it.

Carla: You can’t pay for it. It’s the quality of food that’s in your neighborhood. It’s your employment opportunities.

Bonnie: Education.

Carla: Education. It’s all of those things. And, as a physician, I have to take all of those things into account, and what’s interesting to me is when I first started my practice, a lot of these buzzwords that are out here, now, like social determinants of health, those didn’t exist or, at least, I wasn’t aware of them. All I knew is that I was trying to take care of the whole patient, and that means, it’s just more than me placing my stethoscope on their chest. I have to understand their financial situation, their educational level, are they employed or unemployed? All of those things factor into taking care of people.

Bonnie: So, what would you say to the younger generation of primary care physicians? From what I understand, who aren’t always as encouraged nor, maybe, are given as much time to look at the whole patient and even consider their zip code before making a treatment plan, treatment recommendations. How do we actually tackle what’s in front of us?

Carla: That is a tough question to answer because a lot of this is on a bigger level. Each one, teach one. So, any student or any resident or any fellow that I interact with that comes through my health center and works with me, you’re going to learn more about the art of medicine than the science from me. A lot of times, I rely on what I call the Mothership down the street. The major teaching institution to give you the science. You’re going to get your science from me, as well, but you’re going to learn the art of medicine. You’re going to learn that you just can’t walk into Mrs. Jones’ room and see her as a hospital follow-up for exacerbation of her congestive heart failure and just say, “Well, what happened, Mrs. Jones? Were you not taking your medicines?” Well, you have to understand that it was the end of the month. She had run out of money. So, she was eating a lot of prepared foods, canned soups, frozen dinners, all of these things that are high in salt or sodium, but she was doing the best that she could with what she had until her paycheck came next week. And so, that tipped her over. If you don’t understand that about Mrs. Jones, then, you’re not doing the best service that you can do for Mrs. Jones.

Bonnie: Or, even, Mrs. Jones may live in a zip code that is also a food desert.

Carla: Absolutely.

Bonnie: Where she does not have access to a grocery store that has the fresher fruits and vegetables. The recommended foods that we tell people, just go out and buy.

Carla: It’s always a problem. When you’re living on a fixed income, you will buy what will stretch the farthest.

Bonnie: Exactly.

Carla: I mean, if you look at the fast food industry, it’s cheaper to get what I like to say is, “That five-dollar holler.” Right?

Bonnie: (Laughter)

Carla: Where you can get a burger, fries, you get a cookie, you get a drink.

Bonnie: Yes, yes.

Carla: Sometimes, you can get two sandwiches.

Bonnie: That’s right.

Carla: You get all of this for five dollars.

Bonnie: Yep.

Carla: But if you want to buy the salad at that same fast food, it’s eight or nine dollars. So, when you do the math, when you’re on a fixed income, you have to make a choice. And so, all those things come into play. So, when you look at where you live and that someone can live, literally, just ten miles from you where food deserts aren’t a problem. Where there’s, you know, tons of grocery stores with tons of healthy food options. And, yes, those same fast food places are there, but, then, there’s also an organic food market, or a wholesale food market, where you get more bang for your buck. See, these are some of the things that contribute to that lower life expectancy. These are the things that help determine what your life expectancy is going to be based on your zip code.

Bonnie: Many times, these are things, these social determinants of health, that are out of one individual’s control.

Carla: Control, absolutely, absolutely, because if you live where you live, then, what else do you have?

Bonnie: What else do you have?

Carla: You have to work with what you have within where you live.

Bonnie: So, I’m hearing from, just an individual perspective, as a healthcare, I’ll say, provider, as a physician or a member of the healthcare team, no matter who that is, we really, need to take a few extra minutes or moments to put ourselves in someone else’s shoes and to ask the questions that we may be afraid to ask, may not be familiar with asking, may be uncomfortable asking, but if you can start with your zip code and taking a moment to understand the context from which this patient comes to you, and then, we can understand, maybe, some of the complexities that that patient is bringing to the t able.

Carla: Absolutely, and I think you hit the nail on the head when you said that sometimes, if we’re not walking in those shoes, as healthcare providers, we don’t get it. And so, that’s that extra step, as healthcare providers, that we have to make a conscious effort to be more aware of, and to address it, whether you feel comfortable addressing it or not. I mean, no one likes to be in an uncomfortable situation, but, you know, we’re here to help people.

Bonnie: Exactly.

Carla: In order to help an individual, you have to do a 360-degree view of that person’s life.

Bonnie: Exactly.

Carla: Because I don’t think that anyone wakes up in the morning and goes, “Oh, my gosh, I want to be as unhealthy as I possibly can. I want to take as many pills as I can possibly take. I just want to feel bad.”

Bonnie: And, I want to have every comorbid condition under the sun.

Carla: Every comorbid condition you can possibly have that’s me. That’s what I want.

Bonnie: Exactly.

Carla: I don’t think anyone wakes up…

Bonnie: Making those choices.

Carla: …says that or thinks that. But, life, sometimes, the hand that you’re dealt, and if you’re in situations where it’s hard for you to undo that deal.

Bonnie: Exactly.

Carla: Then, we, as healthcare providers, have to work within the means of what these individuals have to work with.

Bonnie: And, help to bring some level of understanding to the table that helps us empathize, and then, maybe even explain, which is your expertise in explaining the Vicious Cycle, how one loss of movement then leads to the other comorbidities that we see in the Vicious Cycle. Sometimes, connecting those dots by being empathetic, putting ourselves in that person’s shoes, I mean, quite honestly, that Vicious Cycle, we should all be talking about that because it lies at the core of really unlocking how someone could actually see their way through or, at least, see how things are connected.

Carla: Absolutely. When you’re dealing with knee and joint pain, and you’re being told that your weight is contributing to this.

Bonnie: Yes.

Carla: Well, as a patient, I’m sure they probably get that, but what they may not get, as you’re describing in this Vicious Cycle, is that with that knee pain that’s going to make you less mobile, and when you become less mobile, you’re going to gain more weight, and then, when you gain more weight that’s going to put more increased pressure on the joint. And then, that’s going to lead to more knee pain. So, there’s your cycle. If we, as healthcare providers, don’t add that extra piece, then, guess what. At the core of that cycle, is one solution, which is movement and movement doesn’t have to equal that dreaded word exercise. Exercise. You know, “Well, Doc, I can’t exercise.” No, but you can move.

Bonnie: But you can move.

Carla: You can move in some capacity. If it’s just sitting on your sofa and if you’re watching TV, every time a commercial comes on, you standup and just sort of march in place a little bit. Or, as you’re sitting there, you flex and extend your leg. Stretch it out, bend it back. Stretch it out, bend it back. You can get a couple of soup cans from the kitchen and do some arm curls. You don’t have to go to a gym. Sometimes, it’s not safe to even walk in the neighborhood that you live in.

Bonnie: Exactly.

Carla: So, again, this is knowing your patients. Knowing that the zip code may affect some of the resources that they have to even want to be able or be able to do some of these things. Some neighbors, it’s not safe to walk the neighborhood at night.

Bonnie: Exactly, exactly. I had a patient once and we were talking about her knee pain. She was genuinely interested in moving more and I happened to ask her, because my mom is a swimmer, I asked her if she liked the water and if there were any community pools or centers around that had a pool and, in fact, there was one in her zip code and I told her to explore looking at some of the water aerobics classes, her face lit up. She lit up and by the time she came back to see me for a follow-up visit, she couldn’t wait to show me her fabulous new bathing suit that she saved up for so she could, then, take advantage of the senior water aerobics class that was close by. And, she was just so empowered by that. She was so empowered that, now, she was taking her health back into her own hands with the hand she was dealt.

Carla: Right, absolutely. And sometimes, it’s just those little milestones.

Bonnie: Exactly.

Carla: You know, I mean, it’s one step, literally, the longest journey begins with what, the first step.

Bonnie: That’s right. That’s right.

Carla: So, sometimes, it’s those little changes, those little steps that can make a tremendous difference.

Bonnie: A tremendous difference. Well, Dr. Harwell, we just want to thank you for your time today. We look forward to hearing more from you in our next podcast. Thank you, everyone, for listening to the Health Disparities Podcast from Movement Is Life. We appreciate your concern, your input, your insight and your feedback regarding health disparities, as we will continue to have conversations with our experts who are working to eliminate these very disparities. Thank you so much, Dr. Harwell.

Carla: Thank you.

(End of Podcast)

download pdf transcription of this episode