1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).
My research and interests at this point are really at the zeroth generation of disparities research. My focus has been on developing new kidney disease diagnostics and prognostics with novel testing. Because this work has been preclinical, we have not yet had the opportunity to appreciate how it will map onto the landscape of health disparities. I predict that this will be become an issue as soon as this testing moves to the clinical stage. On the one hand, the expansion of kidney disease biomarkers could make the recognition and treatment of clinical disease more equitable by introducing high-quality, objective means to measure kidney health. This is particularly relevant in contrast with the clinically dominant means of measuring kidney function—serum creatinine. The equations developed to translate creatinine into estimates of kidney function include a “race” variable based on the validation studies in the United States. The inclusion of an ill-defined, social construct in a supposedly objective clinical measure is problematic and has deservedly generated controversy. My hope is that new tests of kidney health will be validated in a diverse, generalizable population and translated to clinical practice without the influence of race, ethnicity, and other social factors. The pervasive nature of social inequalities, however, will make this difficult so we will need to be mindful of how novel measures are applied. Looking very far down the road, third-generation research involving kidney health testing should be focused on the equitable implementation of testing and ways that testing can be used to put all patients on an even footing in terms of access and follow up.
2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Gottleib article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level.
I envision a future in which improved testing can deliver a high-resolution picture of early kidney disease that can allow targeted treatments to either arrest or slow the progression of the kidney dysfunction. Social determinants can act to oppose these forces by limiting access to better testing in the first place or making it more difficult to access the level of care needed for good follow up. One option would be to provide patients with health counselor or advocates in the community, who are easily accessible and will be able to remove barriers to care. For example, these advocates might identify patients with abnormal testing and help them schedule and attend follow up visits, fill prescriptions, navigate repeat lab testing, log blood pressures to titrate antihypertensives, and so on. Gottlieb et al. (2016) showed the power of interventions that assigned human beings to navigate the healthcare system along with patients. This type of proactive intervention was more effective than just providing targeted intervention (closer to the current standard of addressing issues with social determinants). Such a strategy overcomes the vicious cycle of disparities driven by social determinants: those things that drive poor health outcomes make it more difficult to address the upstream determinants.