For 25 years, Deborah L. Crabbe has driven up Broad Street to Temple University, where she is a cardiologist, attending physician, and professor of medicine at the Lewis Katz School of Medicine.
One day, her commute took her near a school where there had been a shooting the day before. To Crabbe, it drove home a reality she knew all too well: What good was it for her to tell people to go outdoors and exercise when their neighborhoods were not safe?
Crabbe specializes in women’s cardiovascular health and has worked her whole career to address disparities in health care — particularly racial and ethnic disparities. The American Heart Association recently announced that, because of her dedication, she will be honored at the 2021 Philadelphia Heart Ball, receiving the Edward S. Cooper Award.
We spoke to her recently about her work.
The population is underserved and what we call an under-resourced community. The community that Temple Hospital serves has a significant percentage of its residents who live in poverty, ranging from 30% to 55%, depending on their zip code. Most of the patients we see are African American and Latino. They have a high number of risk factors for cardiovascular disease. They have hypertension, diabetes, obesity. Most of them have a sedentary lifestyle, and they have poor access to healthy foods. They are unlikely to walk and get exercise because the neighborhoods are sometimes questionable.
In the Temple Hospital catchment area, about 41% of the residents have high blood pressure. That’s a lot of people. Especially for African Americans, hypertension is a big determinant of their future risk for cardiovascular disease.
Cardiovascular health equity has to do with eliminating the disparity between populations, so there really is no difference between the health outcomes people have based on where they live, their income, etc. It is tied very closely to the concept of social justice.
One of the things that became apparent when I started to work at Temple is that there are huge challenges in the ability for me to execute the care I’m giving because of the patients’ social circumstances. So you might ask, is there cardiovascular health equity in North Philadelphia? In my opinion, no. For example, the premature cardiovascular disease death rate is higher there compared with the remainder of the city.
To illustrate the impact of social circumstance on health, let me describe two patients.
Patient One lives in Rittenhouse Square. Chances are, they had a good education. And because of that education, chances are they’re going to have a job that pays well. They’re going to have health insurance, so they’ll have access to health-care resources. When they have a good education, these folks tend to have better health literacy; they are able to reach out and find information. They might also have a better experience in the health-care enterprise, so they might have more faith in the health-care system. With all of that, their life expectancy might be 76 or 77 years.
Patient Two lives in North Philadelphia. Chances are they’re going to have issues from the get-go with having access to healthy foods. They’re not going to be buying high-quality food. Of the residents who live in my hospital’s immediate service area, only 36% have education beyond high school. In today’s world, that limits their opportunities to have a good-paying job, so they might not have health insurance. They might have some distrust for the health-care system. And they certainly don’t have the health literacy to understand how to live a healthy lifestyle. Their life expectancy will be less than the Rittenhouse patient.
All of these things create an inequity. We write on people’s medical charts, “eat less fat, eat more fiber, get more exercise.” But how does the North Philadelphia patient do it?
When it comes to the importance of making a living wage, studies have shown a relationship between increasing family income and a reduction in cardiovascular mortality.
Before anyone ever comes to see me, as a cardiologist, these particular living circumstances have been going on for years. So when you look at the health of a community, we’re learning that it’s not as simple as we used to think it was. The zip code you live in can impact your health greatly.
We have to have a complete focus on creating a culture of health for the residents of North Philadelphia. We provide acute-care services for these residents. That’s not the problem. But it turns out that providing good medical care for a community only accounts for 20% of all the things that contribute to the overall health of the people in the community. These other factors — how you live, what your circumstances are, your ability to care for yourself and be educated — all are a prerequisite for which way you go in life.
In 25 years of driving up Broad Street, I’ve seen plenty of fast-food restaurants and not a lot of health messages. Every once in a while, they’ll have an anti-smoking campaign, and they’ll put up a sign. And recently there has been a push to increase access to farmers markets. That’s a step in the right direction. But we need to do much more. We need to be vigilant. We really need to start thinking about how we can create a culture of health.
The state has resources, but I would challenge them to utilize them better. I would love to see a much more coordinated use of these resources and improved integration with the hospitals. We need much more collaboration.
My passion is women’s health, and heart disease is the number-one killer of women. Women, as a group, regardless of age, tend to be considered a disparity group because of the way they have been treated historically, in society, and also because of disparities in cardiovascular disease outcomes. African American and Latino women tend to be the least-educated among women about cardiovascular disease risk factors. African American women have poorer outcomes and higher death rates from cardiovascular disease.
I see this play out in one particular medical condition: heart failure. The women I care for tend to be in their mid-50s. These women, like most women, are the center of the family. They may still be taking care of teenagers or helping with the grandchildren. So, when Mom gets sick, it’s a problem for the rest of the family. Things deteriorate. Heart failure is a condition where you need to be able to do things for yourself, in addition to taking the medication. If you don’t have health literacy, it’s problematic.
I was able to get a grant to help bring heart health education to the community through WomenHeart, a national organization that supports women living with heart disease. They recognize that African American and Latino women are underserved when it comes to receiving heart health education. I would like to see it be sustainable in North Philadelphia. The residents deserve it. It would help us address the disparity of health literacy in this population.
I do think that there is hope. Since COVID-19, we are all more aware of these disparities. They are no longer an abstraction for the general population. COVID-19 has shined a light on them. I think there is a greater will to tackle the problem. And I think there will be more receptiveness toward being innovative in trying to solve this particular problem, which we are more than capable of doing.