HER HEALTH EQUITY MESSAGE BEING HEARD
Doctor has long sought to find and fix underlying causes of disparity
Dr. Thea James began to suspect something important was missing from her medical school education soon after arriving in the Emergency Department of Boston City Hospital as a young resident in the early 1990s.
Every day, James diagnosed the ailments of patients in the busy safety-net hospital and wrote detailed treatment plans designed to fix them, just as she’d been trained. And every day, many of those same patients would return in worse shape than the last time she’d seen them. It was out of frustration that James hit upon a new approach.
“What would it take,” she began asking them, “for you not to come back here again?”
The answers were often surprisingly straightforward. One diabetic patient had been prescribed insulin that needed to be refrigerated. He told James he was homeless and had no place to put it. Another was scheduled follow-up appointments that conflicted with a job he couldn’t afford to miss. Some just needed a person to listen to their problems and answer questions — someone like James, a Black doctor who understood how it felt to be dismissed, not heard.
“In medical school, they teach you about disease and how to treat it, not necessarily about the human who happens to have that disease, what their perspective is on it and how it even happened,” James said. “And without that, what is your likelihood of being able to help them?”
Today James has a far loftier title and, as vice president of mission and associate chief medical officer at what is now called Boston Medical Center, a lot more influence. And, the lessons learned all those years ago remain foundational. For the last decade, she’s infused that patient-centered perspective into a array of programs to empower people to help themselves.
Now James is applying that playbook to one of the most intractable problems in pub
lic health: reducing persistent racial disparities in health outcomes that were laid bare during the COVID-19 pandemic. Her work highlights a simple but important truth: One main cause of racial health inequities is the tendency of hospital systems to dehumanize and dismiss patients of color and not consider extenuating factors. A growing body of evidence suggests something as simple as placing a greater focus on patient input, and improving communication, could make a big difference.
Early results from this initiative BMC launched in 2021, called the Health Equity Accelerator, are promising: In its first 12 months, BMC reduced racial disparities in a key marker of diabetes risk in Black men by 39 percent and lowered the rate at which new mothers are readmitted to the hospital for pregnancy-related complications an estimated 19 percent. Those results, James suggests, are just the beginning of what she expects from an initiative guided by a combination of hard data and consultation with patients themselves.
“When you see data that shows a poor outcome, traditionally what you’re taught is to go into a room and try to solve the problem with the experts,” she said. “But you can’t solve the problem without the subjects of the data being in the conversation.”
In Boston public health circles, where James, a natty dresser known for her signature oversized designer glasses, is a prominent figure, her singular focus on patient input and empowerment is finally resonating. The alienation and distrust many people of color have of medical institutions meant to serve them are now a widely acknowledged driver of poor health. During the COVID-19 pandemic, public health officials were able to reverse stark vaccination disparities by partnering with trusted community leaders and designing programs with patient needs in mind.
“Patients and community members have the solutions, it’s just oftentimes we’re not really listening to them,” said Dr. Bisola Ojikutu, Boston’s public health commissioner. “That’s been a theme that Thea’s carried through all her work.”
James first rose to public prominence in 2006 during a surge in youth violence. At the time, the ER at BMC was treating 70 percent of the city’s gunshot and stabbing victims. James had begun reading the tattoos on the young men she was treating. Years later she can still quote the inked messages of despair: “Born to be hated, dying to be loved.” “Living is hard, dying is easy.” “Death is nothing, but to live defeated is to die every day.”
“People standing outside the trauma room were calling them thugs,” James said. “I realized they just were hopeless.”
In 2015, James was appointed BMC’s vice president of mission, overseeing a long list of programs one might not normally associate with hospitals, including a rooftop produce and vegetable garden that feeds 5,000 families a month, an economic justice hub that offers financial education and job opportunities to underemployed parents, and a program that, since 2016, has connected more than 6,000 families with tax preparers.
“People can’t prioritize their health when they’re prioritizing survival,” James said.
She sees her role at BMC’s health equity accelerator as an extension of her previous work. The intention is to look at the data and confer with patients, to “co-create” solutions.
The effort has identified five areas of focus: maternal and child health, infectious disease, behavioral health, chronic conditions, and oncology and endstage renal disease.
Early success has come in the area of maternal health. In the US, Black women are more than three times more likely to die from pregnancy-related causes than white women (and five times more likely if both have a college degree). Many of the disparities manifest as pregnancyrelated high blood pressure, a potentially fatal condition that is 67 percent more prevalent in BMC’s Black patients than in non-Hispanic white patients.
The program, according to preliminary estimates, reduced postpartum patient readmissions for hypertension among 1,260 perinatal patients by nearly 20 percent over a 12-month period. The key was a simple tool: a blood pressure monitoring strap that sends readings via cellphone towers directly to patient medical records, where they are monitored by a nurse.
The best way to treat dangerous high blood pressure in an expectant mother is to deliver the baby. But data showed it took BMC doctors almost twice as long to perform urgent C-secCox, tions on Black patients as on white patients. To eliminate the possibility of implicit bias, BMC standardized its protocol for deciding when to induce delivery, cutting the review period for Black women nearly in half, to 50 minutes. That led to measurable improvements in the health of newborns.
Lorenis Liriano had two of her three children at BMC, one before the health equity accelerator was created and one after. When she was admitted in 2020 during the pandemic, she was greeted by a white female doctor with blood-stained hands.
Having given birth to her eldest daughter in New York, Liriano knew she had a condition called precipitous labor, which results in an extremely fast birth marked by intense, painful contractions. She begged for an epidural immediately but was given a COVID test instead.
“She didn’t really take me seriously,” she recalls. “I was dismissed.”
By the time another doctor had finally heard Liriano out, it was too late; her delivery was excruciating.
Liriano’s experience in 2022 was fundamentally different. Prior to giving birth, she was invited to attend weekly collaborative learning sessions with a midwife and other pregnant women of color, in which she learned about breastfeeding and the risks of postpartum depression.
She also was taught to “listen to her body,” and speak up for her needs. During her labor, a “birth sister” squeezed her feet every time she had contractions, while a midwife played her favorite Christian music, talked her through the pain, and coached her fiancé.
“It was the best labor that I had,” she said. “I felt very loved, very cared for. I learned I have choices, that you can challenge the doctor. They empowered us to know about our bodies.”
”It’s the same model from the ER of listening to people and having them inform us about what the root causes are,” James said. “That informs us on what the solutions should be.”
‘Traditionally what you’re taught is to go into a room and try to solve the problem with the experts; you can’t solve the problem without the subjects of the data being in the conversation.’
DR. THEA JAMES