BETA - What are social determinants of health? How are they related to lack of access?

So, social determinants of health are those things which really kind of self-descriptive of what determines how healthcare is delivered. And there are lots of things that are involved in that. And so, one social determinant of care is sort of the biology, because the incidence of myeloma occurring in different ethnic groups can't be explained by alcohol, tobacco, other exposures. It's something that's biologic that we really don't have an explanation for. Lots of studies looking at that but don't have an explanation for. So, biology is one social determinant of health that makes those differences, those disparities. Other things are socioeconomic status. So we know that socioeconomic status, because of a lot of the things that have happened in this country and around the world, that people of different ethnicities have different socioeconomic status. How much money they make, what their insurance programs look like, what access they have to care. And so, some groups have well-insured and have access to a lot of medications, while other groups don't have that. Myeloma care costs a lot of money. And patients that are under-insured or on Medicare without private insurance have more difficulty engaging in a lot of those really good myeloma therapies than other groups. There was a study that looked at the CERE database, which is a massive database throughout the United States, and saw that patients that have high socioeconomic status do better than patients that have middle socioeconomic status, which do better than patients that have low socioeconomic status. And because that low socioeconomic strata is a lot of patients of ethnicity built in, and rural patients built in, their overall survival is lower because of really financial constraints of being in that low socioeconomic strata. So that's the social determinant of health. Attitudes. And so, some communities have very negative attitudes against the medical establishment. Really, I should say, more distrust of the medical establishment based on a lot of history that has happened with clinical trials and such. And so, they're less likely to engage in clinical trials, less likely to engage their doctors, which again, is a social determinant of health. Environment is another social determinant of health. There are comorbidities like obesity, heart failure, social determinants of health. But all those things kind of make the playing field a bit unequal. Some of those are things that we can hopefully change in the future. Some of those things are hardwired. So in terms of access, there are quite a few disparities that exist. And some of them have been highlighted in the literature. That includes things like lack of insurance, for example, or being underinsured. And so, not being able to have continuity of care or continue your care, except getting sporadic care, maybe in the emergency room setting or something like that. Not being close to a health care center that will have a myeloma specialist or a provider that understands or has the resources to care for you with multiple myeloma. Transportation access, again, weave into the fact that there's a lot of socioeconomic barriers that already exist. And those are, you can't rip apart the socioeconomic from the health care. That's all entwined. And so all of those barriers come together and they compound the situation. And so, if you don't have the right insurance, you may not be able to go ahead and afford the care that you need. So that is a very much a very good question. That is very much a social determinant of health, that especially in myeloma. Because we know that myeloma care is better in the high academic centers. And so, the excellence of myeloma care, that there's better survival at those places. However, some groups are less likely to engage those academic centers. There's, again, some of those distrust of clinical trials and distrust of the medical system that has been fostered for generations makes people less likely to engage some of those academic centers. And so, even though they may live next to an academic center, they're less likely to engage it. And part of that is the idea that's been studied, that some communities are worried that if they don't engage their community provider, they don't engage that community hematologist, that that hematologist may go out of business and therefore their community will be left doctorless. And so, they're more likely to engage these community centers than the academic centers, which again is another sort of difference between because other, you know, if you live far away, seeing and going to an academic center is no problem because it's not part of that community. But the one important thing, one important thing is that when, if all things being equal, so especially patients on clinical trials and patients treated through the VA system. So in the VA system, everyone gets treated the same because the VA tells you, you have to treat myeloma this way. So everyone gets the same treatment. We look at the VA medical system, you know, clinical trials are built in very specific regimens that patients have to stick to. When you look at the VA medical system, you look at the RVD 1000 study where they enroll a thousand patients at Emory University and even the most recent Griffin study with the DERA RVD versus RVD. You look at those three studies, all things being equal, African Americans have the, have equal outcomes and the VA study said that may even have better outcomes than Caucasian patients. So all things being equal, outcomes are the same. But when you throw in those social determinants of health, it makes the inequality happen.