Podcast transcript: How digital solutions will help close the health equity gap

Adlai Goldberg

Hi, I'm Adlai Goldberg, EY's Global Digital Social and Commercial Innovation Leader for Life Science companies. Welcome to our special podcast series exploring how data and technology are at the core of solving some of the most significant challenges in scaling and delivering cell and gene therapies. We'll be covering a wide range of topics through conversations with industry leaders and stakeholders from and across the healthcare, life sciences and technology spectrums.

Addressing healthcare inequality is a global challenge. Healthcare disparity doesn't just begin at the time a patient is diagnosed or treated, it goes back much further, to clinical trials and the fact that low enrolment rates of minorities would generate results that are not reflective of populations. And while Covid-19 has both given rise to a groundswell of societal demand for equal treatment of all people, the pandemic has also highlighted the health disparities across populations. For Dr. Yele Aluko, EY's Chief Medical Officer and Dr. David Rhew, Microsoft's Chief Medical Officer, finding opportunities to provide health equity is a passion they both share. I had a chance to sit down with both of them to discuss why disparities exist, the root causes and the digital solutions that will help to level the playing field. It was a fascinating and eye-opening conversation and we even brought up the topics of emerging therapies and advanced therapies that are soon to hit the market. The way forward requires strategic insight from the healthcare value chain, using data and analytics to not only identify care gaps, but to then develop tactics and solutions that will help to close these disparities. It was a fascinating conversation and health equity is an important global mission. Striving to achieve it ensures that everyone has a better chance of fulfilling their life's potential with access and availability of appropriate healthcare.

Good day, everyone. I'm excited to have Dr. Aluko and Dr. Rhew join me on this podcast, where we're going to explore health equity and the framing of the health equity challenge that we're faced with today.

And so, to begin with Dr. Aluko, Chief Medical Officer from EY, and Dr. David Rhew, Chief Medical Officer from Microsoft are here to explore this topic, and I'd like to kind of kick us off, if I may, by asking you, Dr. Aluko. If you can share with me why and what has happened in your career that has made health equity so important?

Dr. Yele Aluko

Well, thank you very much, Adlai. It's a pleasure to be here with Dr. Rhew. I practiced cardiovascular medicine for 25 years and prior to that, I was in training for several years, and my passion around health disparities was spawned when I was a fellow in Interventional Cardiology. I was the only African American fellow in the program in Massachusetts, and it occurred to me about six months after being in the interventional program as the only fellow, that I had done an angioplasty, an interventional procedure, on only one African American man, who happened to be an executive at Kodak. That began my interest in trying to understand the issues around access challenges, particularly in populations like African Americans that had significant at-risk outcomes in heart disease.

Goldberg

Thank you Dr. Aluko for sharing that experience that you had at the young age of your medical career. And Dr. Rhew, we've had a chance to speak in the past and you've also mentioned health equity or the inequality of health as something important to you. I'd really like to understand what got you focused on this topic.

Dr. David Rhew

Thank you, Adlai, it's a pleasure to be here and a pleasure to join you and Dr. Aluko. This is similar to Dr. Aluko's story where, early in my career I started noticing some inequities, just differences in care and how care was delivered. I thought it was rather perplexing how, within one hospital we would see significant variations in care, and this was around the types of procedures that were performed, how long patients were staying in the hospital, what type of treatments were offered. And I always wondered whether patients were actually getting better care through one route or the other.

And so, the more I studied that, the more I realized that in fact, the more you did oftentimes led to the worst outcomes, and it was surprising when I started looking more broadly beyond our hospital and across other hospitals and even states, that these patterns persisted, these variations in care, and that's really gotten me pretty interested in understanding, not just from a curiosity perspective, but also why is it that some of these disparities or these differences occur. And oftentimes it occurs because of reasons that go well beyond the science and then these are the things that oftentimes I'm trying to find ways within my role within Microsoft  to be able to address some of those disparities and inequities that we see today in health care.

Goldberg

Some examples that are driving this inequality can be found in cancer and cancer treatments. There are also vulnerable populations and in fact, there are high percentages of cancer in certain racial groups and even certain socioeconomic groups. I'd like from your perspective, Dr. Aluko, why do these disparities exist?

Dr. Aluko

First, we need to understand the context of health disparities and how they relate to health equity and inequity. Health disparities speak to different outcomes for specific health conditions that certain groups of people might experience within the health system and, for example, we all know that more black people have died from COVID-19 than white people. That's an example of a health disparity that's occurred within a specific health condition, COVID-19, and it's experienced within a specific population compared to another, black versus white. So, that therein is the context of health disparities.

Now, secondly, health equity is an aspirational goal, and it will exist when these disparities are eliminated. Doing will enable all people, irrespective of their designation, be it, be it race, be it social status, be it gender, enabling everybody to achieve similar outcomes.

Goldberg

And building on what you're saying, Dr. Aluko, and something that you referred to early on in your introduction, Dr. Rhew, was also incidents in delays of treatment or diagnosis. Curious in your experience as a practitioner, what you've seen and experienced in your role in Microsoft, why are there incidents of delayed treatments and diagnosis?

Dr. Rhew

Well, as Dr. Aluko shared, it is multi-factorial. There are certainly issues around just simply providing general access to care, and I'll start with that because we know that care is not equally distributed and oftentimes, in our efforts to provide more efficient care, we don't realize that there's some inherent biases in our approach. I'll start with some of the things we've seen more recently. Trying to get a vaccine. To get the COVID-19 vaccine, they're available at mass vaccination centers, retail clinics, you must schedule online. Not everyone even has a broadband.

And then you start going into the issues of availability. Some people are working, and they don’t have time to take off. There's been a lot of questions as to whether if they were to get the vaccine, is this something that they would feel comfortable with? And as we start thinking about some of the challenges that we run into, there are many reasons why care gets delayed or, in some cases gets missed. And certainly, when you have delay in things that are going to have long-term impact, such as cancer diagnosis. Then, by the time they do appear, it's much more advanced, it's harder to treat. And then now you're talking about a longer, more complicated course, so it's a ripple effect. Starting with the fact that oftentimes we haven't made it easier, more accessible.

And I want to highlight one concept which we oftentimes tend to overlook – the difference between equal treatment and equitable treatment. Equal treatment is applying a similar standard to everybody but, because of these underlying differences in the fact that some are more vulnerable, disadvantaged and other factors, that equal treatment doesn't necessarily mean equitable. Equitable is helping to lift those that are vulnerable, high risk, give them an even playing field and allowing them to be able to achieve the same type of outcomes as others. And that's what we're looking for. We're looking for opportunities to provide health equity.

Goldberg

Gentlemen, we've been talking about health equity or inequality in the diagnosis and treatment of conditions that people may be facing. But as I understand from what I've read and have learned from you both that this disparity doesn't just begin at the time of diagnosis and treatment. It finds its way back earlier in the process when we're designing and trying to develop drugs and beginning that process through the clinical trial programs.

Historically, the enrolment rates for minorities in clinical trials have been extremely low and therefore, not reflective of the diversity of the populations that we're talking about today. I'm curious, Dr. Aluko, what is driving inequality in areas such as these clinical trials?

Dr. Aluko

I'll provide probably just two areas for introspection here. First, the sentiment of minorities toward clinical trials has been influenced by the long and painful history of medical experimentation on black and brown bodies, and this goes back centuries in the history of organized American medicine. And this is not just historical. There are recent traCOVID-19atic memorable reminders that tend to reinforce the distrust that minority populations have had for a long time with the health system. Therefore, spontaneous participation by minorities and clinical trials are going to invariably be challenging if clinical trial organizations are not aware of this cultural context, or not understanding of it in a manner that enables them to have nuanced approaches to designing clinical trials for inclusivity.

Now that's not by any means the only reason. And I will posit that the larger problem, in my opinion, is that the clinical trials industry has not prioritized seeking the insight that comes from diverse enrolment. And, for this reason, I'm being provocative saying this, but I will be provocative. For this reason, clinical trial organizations have just not been able to develop efficient, effective targeted strategies that will penetrate minority populations at, with ease and, by so doing, increase diverse enrolment. Logistically, it's easier to enroll populations that are easier to penetrate, and if the perception is that minority populations are hard to penetrate, clinical trial organizations may gravitate away from them. Especially if the goal is to get as many participants enrolled as quickly as possible, to take the drugs to market and recoup the R&D expenditure and turn a profit. So, those are two broad categories, there are others. But that's something for us to consider as we seek to engage clinical trial organizations to develop more effective strategies.

Goldberg

And one of the areas where I've been spending some time with Dr. Rhew recently has really been around the emerging advanced therapies such as CAR-T, MRNA and I know we spent a lot of time these days thinking about vaccines,  in relationship to COVID-19 and so forth. Given the issues that you've raised, Dr. Aluko, in relationship to clinical trials, Dr. Rhew, how do you think those challenges in enrolling diversity in clinical trials will actually translate or affect advanced therapies, again, such as CAR-T, MRNA or, COVID-19 vaccines and whatnot. How might this affect, how will this translate into the advanced therapies that are now coming down the road?

Dr. Rhew

The advanced therapies that you've mentioned evolved within a category of precision medicine, in which we're looking to specifically provide treatments that are designed to help a specific individual with a specific type of genetic profile or a cancer that has a specific type of profile. And, because of the sheer nature of trying to be as specific as possible, if we don't account for the broad diversity of genetics in our clinical trials, then what we have done is we have narrowly targeted a specific group of individuals, but in the application we have then opened it up to other individuals. And this then poses the question as to one, whether it's just as effective, just as safe, and is, whether there would be potentially other factors that we need to consider which were not discovered in the clinical trials process. 

And, for that reason, what was encouraging was to see that many of the clinical trials, they did seek to try to obtain a diverse population, specifically for the COVID-19 vaccinations. In the past this may not have been as much of a priority for other organizations, recognizing the fact that this would need to be rapidly approved and then applied universally. This was something that many investigators rightfully saw as an important need. We need to continue to do this  for all types of precision medicine type of therapies, as well as other types of  medical treatments. What we find is that, as Dr. Aluko had mentioned, it's far easier to just simply enroll folks, see who comes and then just basically get that published, but when we think about the generalizability of these treatments, you have to look at the population as a whole, and make sure that you've got an inclusive study design.

Goldberg

I mean, you've really outlined for me the challenges that we're facing, both historically, systemically around the disparities and why they exist. We've also started to outline the vision, and I think you both describe it well, around how do we start to create health equity. What I'd like to turn to now is really what are going to be some solutions that are going to close the gap on the disparities and really start to move us much towards kind of the health equity that we were talking about? And so, Dr. Aluko, I'd really like to understand from your perspective, really from the solution point of view, what do you recommend? How might we create more health equity in today's world?

Dr. Aluko

There are multiple stakeholders in the health care value chain, and each different stakeholder group has an opportunity to develop business models within their particular competencies that help to drive health equity. We take a provider health system for example. There needs to, first, in my opinion, be a deep alignment within senior leadership that there is a problem around health disparities, and that it does require strategic insight. In other words, developing a health equity enterprise-wide strategy that they themselves will be held accountable to by way of providing transparency in performance, by way of optimizing the patient journey irrespective of background, and by way of, of holding, using data and analytics in a near real-time manner to provide insight to providers that are delivering care, and identifying care gaps, not just identifying them, developing tactics that will close them.

Specific to the pharma industry, I think it's very important in that stakeholder group that this alignment with client, within the clinical science, clinical trials enrolment process, the alignment that there's a benefit from total population insight from clinical trials is important. I think that we've had a tepid approach to that in the past. Once that alignment is done, it's easier to develop strategies that seek to penetrate  challenging demographics, and these strategies will focus and be solutions that are going to be very pertinent to specific demographics that needs to be the case for precision medicine, even though it may be seemingly difficult to do so.

And one last thing I would like to say is that , identifying genetic-based diseases that might benefit from precision medicine, there are certain genetic based diseases that tend to disproportionately impact minority populations, like sickle cell anemia, sarcoidosis, whereby designing clinical trials should impact those populations. And I will say that sickle cell anemia has been stated to be largely ignored by research and development. It impacts black people more than white people. And another type of disease that impacts minorities is thalassemia. The different types of thalassemia are one of which impacts black people more than others, and Asians as well. With identifying those particular diseases that seem to have some race based genetic predispositions should enable clinical trials to be designed with this in mind as drugs are being manufactured to medicate those diseases.

Goldberg

Dr. Rhew, with your perspectives from Microsoft, I would really like to understand how you believe digital solutions will help us to overcome the challenges of health disparities?

Dr. Rhew

Yeah. I'd like to start with some of the points that Dr. Aluko pointed out. The first step is awareness and acknowledgement that there is an issue that needs to be addressed and that we have an opportunity to address this early on. And when we think of the things that Microsoft has been involved in terms of building technologies that can be used by millions of individuals to make things easier, what we have also thought of in the design, is a more inclusive approach. So, for instance, does the user interface accommodate for those with poor vision, with decreased hearing, poor mobility, decreased cognition?  Have we thought through the usability? Have we thought through the fact that some people don't even have broadband and that we need to have paper-based solutions or call center based solutions? And as we built products and offered solutions, we've tried as much as possible to make sure that we've thought through the variables and then incorporated them into the design. 

And then, as we go through and learn more about what can be done, we then are able to provide an opportunity for everyone to take advantage of the technologies. We've seen digital allow us to be able to communicate rapidly and seamlessly between across borders and across multiple different country lines and share information that has had a dramatic impact on COVID-19. We have seen an ability for us to connect to family members and other people, and so now that's something that's possible not just for the digitally savvy but for folks that previously never used digital. We’re realizing that to get to the point where everyone can take advantage, we must start with some of the basics. Access is the first, and then affordability, digital literacy and then health care literacy. And then, as we think through all of those, those require an approach that involves people. 

People training other people, people understanding how these technologies can be used in different settings and adjusting for them and making sure that we've thought through the user experience and removed as many barriers as possible. I'd like to also comment on the fact that other interventions that in health care that have great promise, tie into what we oftentimes refer to as social determinates, or social influencers to help. When we start recognizing that housing, the one's job, food, all these types of elements, transportation are huge either barriers or enablers. And if we can find ways to identify and facilitate, we can, in many ways improve the overall health of the community. So, this is an exciting area, where oftentimes we have neglected the importance of the socioeconomic elements that each of us lives in, but they have a dramatic and direct impact on one's health.

Goldberg

Dr. Rhew has really opened up the other side of this coin, which is the other determinates towards health. I would be very curious your perspectives, Dr. Aluko on that.

Dr. Aluko

Well, I agree with everything that Dr. Rhew said. I would caution us and health system leaders with the reality that, absent of a deliberate strategy, digital platforms may accentuate the existing digital divide. Dr. Rhew mentioned telemedicine that happened with COVID-19. We should remember that telemedicine was in existence as a service prior to COVID-19 with minimal adoption or uptake, for several reasons. One of which was cultural between physicians and patients and not, the main one was reimbursement. But it's been said that, with telemedicine, there are decades that nothing happens, and then within a matter of six weeks, decades happen. In other words, for decades we have been talking telemedicine, and within a matter of six to eight weeks, the entire health industry, provider industry in the United States, positioned themselves to deliver telemedicine because of a crisis. We figured out a way how to do it using IT and digital platforms. But it also has been noted that there has been in certain pockets and specialties less efficient communication with minority populations despite this innovative technology.

Fundamentally, IT and digital platforms should be levers that enable enterprise strategy and, absent of an enterprise strategy to engage minority populations and tactics developed thereof, and then enabled by technology, we may not achieve the goal we are seeking if that goal is diverse enrolment, diverse to at-risk populations. This problem about digital platforms, for clinical enrolment, by the way, this concept is not new. I mean it, it's existed for a while. It goes back twenty years. In fact, there's been an increase in digital methods by more than a hundred-fold, from my recollection, over the past twenty years. But, despite that, the enrolment, the more diverse enrolment hasn't occurred. So, we've got – like telemedicine, we have the technology, we just haven't devised a strategy, and we have not held ourselves accountable to executing on that strategy.

Goldberg

Dr. Rhew, was there any breakthroughs in the diversity of enrolment through digital technologies in relationship to COVID-19? Or did we find that the same story telling itself over again with the recent crisis that we've just been through?

Dr. Rhew

Well, one of the things that we were able to do, despite the fact that it was so difficult to do the traditional clinical trial was to leverage digital tools to provoke enrolment and for conducting clinical trials, and that benefits everyone. But I'll say that there is always the risk when you rely entirely on digital, to get a population that may not necessarily be reflective of the general population. And so, for that reason, I see it as an incredibly valuable and powerful tool, but you will still need to be augmented with efforts to ensure that you've met the criteria for establishing enrolment that's diverse and representative of the population. The examples that I can cite, what we have done  early on in the pandemic was we realized the power of an AI-based chatbot, and that chatbot enabled people to have questions answered very quickly, efficiently, triage to specific areas and, and given very much individualized recommendations.  That was incredibly powerful when you have a lot of people calling into call centers,  a lot of people hitting websites, and that was not just during the pandemic at the very beginning, but also even with the vaccinations we saw an incredible role for how this could handle that capacity and then additionally, within the context of understanding what the concerns were, directing them to other areas. What we found were subsequent examples of how that same chatbot technology could be used for clinical trial enrolment, for plasma donation and a variety of other areas that were incredibly important and remain so as part of our COVID-19 response. So, I think that clearly there are, there's a role for digital technologies. We don't want to over-index on it but we do want to leverage it and also make sure that at the same time, we have enrolled the diverse populations we're interested in.

Goldberg

In the final  moments that we have together, I'd like to throw you each the same question. I'd like to understand what you believe we can achieve in our lifetime to close the disparity gap.

Dr. Rhew

It's remarkable, when you think of how much innovation has occurred because of necessity,  and the fact that we were able to develop a vaccine in less than a year and when it previously it took many years, largely because of the fact that we have technologies that enabled it and we had a focus on the issues, and with that focus came incentives, and a variety of other ways that we have removed the barriers. Today, health equity is a topic that we talk about regularly. I remember when I was in training in medical school, I don't think we even heard about it once. Clearly, it’s now top of mind. It's wonderful to see organizations and communities embracing the concept. But now this is the opportunity for us to be able to take advantage of it and accelerate the pace of innovation, the addressing of the social determinants and social influencers to help building programs that are sustainable and finding ways that we can address  the needs of the most vulnerable and the highest-risk individuals. And that's really what all of us have signed up for when we became physicians and other health care providers. We've now realized that sometimes our initial efforts have missed the most vulnerable and so we have to make sure that we don't go too quickly without bringing them along. And to me, that's a great opportunity for us to be able to start innovating together.

Goldberg

Thank you, Dr. Rhew, and Dr. Aluko, in this lifetime what do you think we're able to achieve on this important mission of health equity?

Dr. Aluko

I feel that we are the beneficiaries now in time of a groundswell of societal demand that is cross-industry, cross-sector, cross-demographics, seeking better outcomes for all people. And this has been illuminated mainly by COVID-19, although this problem around health disparities has not, is not a new one. The ability to eliminate disparities and to move this away from a conversation to actual solution is what I feel we are positioned to be able to do, and in my lifetime, I hope we will be able to do. The, the notion of health disparities oftentimes raises a racial connotation that blacks are more adversely impacted by whites and latin x as well. This goes way beyond racial connotation, although the racial issues may be the most abject. We need to understand the context of vulnerable populations that include racial minorities. They include gender minorities. They include other vulnerable populations like the elderly, the homeless, the disabled. And implicit in providing health equity, means all people, as mentioned, within vulnerable populations, have a good chance of achieving their life's potential in the health trajectory. If we're able to do that, we essentially have transformed the industry whereby as Dr. Rhew mentioned earlier, we're able to eliminated care variation and develop standardized care for everybody, and understand gaps where they exist, but beyond that develop process to close those gaps. And that's what I hope to see in my lifetime.

Goldberg

Gentleman, what an inspiring way to close this discussion that I'm having with you. Dr. Aluko, Dr. Rhew, I want to thank you very, very much for taking the time to explore this really important issue that we are facing right now around health disparity, and I've greatly appreciated COVID-19 how you have also outlined our journey towards building better health equity amongst the variety of populations that the health care community needs to serve, and so, with that, let me wish you all the best and, once again, thank you very much for spending time with me today.