Health Disparities: Insights from Nebraska to Nairobi with Dr. Ngaruiya

Health disparities are differences in health outcomes between populations that are linked to social, economic, or environmental factors. Health disparities negatively impact groups who systematically experience greater barriers to care whether due to race or ethnicity, religion, gender, age, sexual orientation, gender identity, geography or many other social determinants. Individual and population health is influenced not just by biology, genetics and behavior but also access to health services, discrimination, socioeconomic status and more. Addressing individual and population determinants help to enable better health outcomes and health equity.

Dr. Christine Ngaruiya, assistant professor in emergency medicine at Yale School of Medicine, is working to decrease health disparities and improve care for non-communicable diseases (NCDs). Born in Nebraska, Dr. Ngaruiya moved back to her familial home of Kenya for the majority of her childhood, returning to Nebraska for college at 15 years of age. Her work previously focused on health disparities amongst minority populations in the U.S. with a recent shift to solutions for NCDs in East Africa. We spoke with Dr. Ngaruiya about health disparities and working between the U.S. and East Africa.

1. What motivates your work in health disparities?

Dr. Ngaruiya: I was first exposed to health disparities during a college course on “Sociology of Health.” I had lived in Kenya and seen extreme poverty in the slums and understood poor access to care. With a more robust health system in the U.S., I was shocked to see such systematic disparities between populations. Racial and ethnic minorities experience have worse health outcomes across conditions, locations and other demographic factors. And so my work began; I did my thesis on the disparities in care for ethnic minority women and this has become a passion to close the disparity in care.

2. How are health disparities and non-communicable diseases related?

Dr. Ngaruiya: NCDs are the epitome of health care disparities. We have the tools, resources, medicine and knowledge to prevent NCDs, but people do not all have access to these. Thus a gap persists between populations with and without access. You see it within the U.S. but also globally. 80% of deaths due to NCDs occur in low and middle-income countries. These are preventable deaths. We have what we need right now to justly address these health issues. I think of it as two sides of the same coin because by addressing one, health disparities or NCDs, we can impact the other.

3. What are common and preventable barriers to care that drive health disparities?

Dr. Ngaruiya: Trust is a main barrier between providers and patients. If there is a difference between the race of the patient and provider there is less trust. There are many historical and sociological factors for this, and it has been shown across populations. Once a patient does not trust a provider, the care is directly impacted.

Cost heavily impacts access and increases disparities. It doesn’t always have to be cost of care but even of transport to care. Copays can be prohibitive and then there are additional costs of medicine. When working with lower income populations, both in the U.S. and in Kenya, if a family has to decide between purchasing medicine or feeding children, the latter takes precedent every time.

Many other factors like time and education also drive health disparities. Many lower income populations do not have the professional flexibility or financial ability to leave work to see a doctor. And education plays a large role; it is less about formal schooling and more related to health literacy and health education. If a patient has not read discharge instructions or doesn’t understand a prescription, then care will not be as successful.

This is why I founded Bridge to Care for refugees in Nebraska in order to provide health education and linkage to care. I went to church each week with a large refugee population, and one time there was a really sick toddler. I realized that I didn’t even know where the family should go for care so how would they know. Through further study using community based participatory approaches, I realized there was a large information gap as refugees and new immigrants were not aware of what a doctor does, when to go to the doctor, and what would happen at a hospital. Health education is a common barrier and accessible fix to contribute to addressing disparities in care.

4. How does your work translate between the U.S. and East Africa?

Dr. Ngaruiya: I believe everyone should think globally. Global is local was coined, I believe, by Peggy Bentley at UNC-Chapel Hill. Global issues have a ripple effect that can be felt locally.

NCDs are global and local; the work I do for NCDs translates simply. In terms of translating work in health disparities, there are health disparities in Nairobi just like Nebraska or New Haven. In Kenya, the disparities are driven less by race and more by socioeconomic class. There is a huge gap between those with and without access to care. While the health disparities in the U.S. are terrible, those in East Africa are far worse.

5. How can providers and companies better use technology to address health disparities?

Dr. Ngaruiya: Technology is changing the landscape of healthcare globally. Rural communities around the world are now being connected. There are new opportunities to affordably and efficiently get care through mobile health solutions with interactive modes of intervention, new modalities for care and remote research. access.mobile has done a lot in improving access and working to address community and patient needs through mobile solutions both in Kenya and more recently in the U.S.

And again it comes back to global is local - technology can play a large part in bridging local needs and global capacity. Technology can assuage health disparities when applied intentionally to decrease barriers to health care for populations who systematically experience challenges currently.