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Category: Diversity, Inclusion, & Accessibility

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Image of a diverse group of teenagers talking. Text: National Minority Mental Health Awareness Month.
Image from https://minorityhealth.hhs.gov/national-minority-mental-health-awareness-month-2024-toolkit

July is National Minority Mental Health Awareness Month! This important yearly observance aims to raise awareness about the unique challenges that impact the mental health of racial and ethnic minority populations. This year’s theme is Be the Source for Better Health: Improving Health Outcomes Through Our Cultures, Communities, and Connections, which emphasizes how the unique social determinants of health of racial and ethnic minority populations impact overall health, including mental health.

Social determinants of health have a profound impact on both physical and mental health. The Centers for Disease Control (CDC) defines social determinants of health (SDOH) as “non-medical factors that affect health outcomes” and can include “the conditions in which people are born, grow, work, live, and age” (CDC, 2024). Five key social determinants of health highlighted in Healthy People 2030 include education access and quality, health care and quality, the neighborhood and built environment, social and community context, and economic stability.

Image of icons used by the CDC for the 5 key social determinates of health.
(CDC, 2024)

Economic stability is a key determinant of mental health. According to Alegria et al. “unemployment, precarious employment, and employment conditions” are linked to “increased psychological distress, even in countries with universal healthcare, where employer-provided health insurance is less essential to accessing services” (Alegria et al., 2018). Economic stability, neighborhood, and the built environment play a role in food security. Lower-income people are more likely to live in food deserts (areas with limited access to plentiful, affordable, or nutritious food). According to a 2020 National Public Radio article, 19 million Americans, about 6% of Americans lived in a food desert in 2015 (Silva, 2020). Black and Hispanic Americans are disproportionately impacted by food insecurity, with 19.1% of Black households and 15.6% of Hispanic households experiencing food insecurity in 2019, compared to only 7.9% of White households (Silva, 2020). 

“Food insecurity and poor diet quality have also been linked to poorer mental health in the United States and Canada” (Alegria et al., 2018). Poor mental health outcomes associated with food insecurity include depression and anxiety. According to Morrison and Frank, there is “a dose-response relationship between the severity of food insecurity and the prevalence of depressive symptoms” (Morrison & Frank, 2023). Food insecurity can also lead to psychological stress responses including “higher levels of anxiety, frustration, and a sense of powerlessness” (Morrison & Frank, 2023). 

Social and community contexts also play a vital role in the social determinants of mental health. Violence within the community can have a large impact on mental health. “Direct and indirect experiences of community violence in adolescence have been significantly associated with elevated depressive, anxiety, and PTSD symptoms” (Alegria et al., 2018). Additionally, living in areas with high incarceration rates is associated with an increased risk of a major depressive or generalized anxiety disorder (Alegria et al., 2018). 

Some unchangeable, fixed characteristics, such as race/ethnicity, nationality, gender, and sexual orientation, also play an important role in mental health. The intersectionality between minority status of race, sexual orientation, and gender identity is an important consideration (Morrison & Frank, 2023). LGBT adults who are also racial/ethnic minorities reported poorer mental health than white respondents (Alegria et al., 2018). Higher rates of suicide have been reported among minority youth who were also marginalized due to sexual orientation and gender identity (Morrison & Frank, 2023). 

It’s important to understand the relationship between social determinants and mental health. “Poor mental health can aggravate personal choices and affect living conditions that limit opportunities” (Alegria et al., 2018). A focus on improving social determinants of health will help improve mental health for minorities who are often disproportionately impacted. “Multilevel interventions aimed at eliminating systemic social inequalities - such as access to educational and employment opportunities, healthy food, secure housing, and safe neighborhoods - are crucial” (Alegria et al., 2018). Primary care physicians can use validated screening tools such as the Social Needs Screening Tool developed by the American Academy of Family Physicians (Morrison & Frank, 2023). Social prescribing, linking patients to appropriate social and community services, is another option for physicians. By addressing the social determinants of health that impact minority mental health through a comprehensive approach, we can work to “advance health equity, reduce health disparities, and Be the Source for Better Health for racial and ethnic minority and American Indian and Alaska Native populations” (HHS, 2024).

References:

Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current psychiatry reports, 20(11), 95. https://doi.org/10.1007/s11920-018-0969-9 

Centers for Disease Control (CDC). (2024). Social Determinants of Health. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html

U.S. Department of Health & Human Services Office of Minority Health (HHS). (2024). National Minority Mental Health Awareness Month 2024 Toolkit. https://minorityhealth.hhs.gov/national-minority-mental-health-awareness-month-2024-toolkit

Morrison, L., & Frank, C. J. (2023). Social Determinants of Mental and Behavioral Health. Primary care, 50(4), 679–688. https://doi.org/10.1016/j.pop.2023.04.003

Silva, C. (September 27, 2020). Food insecurity in the U.S. by the numbers. National Public Radio (NPR). https://www.npr.org/2020/09/27/912486921/food-insecurity-in-the-u-s-by-the-numbers

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Aubrey Gordon is the creator of Your Fat Friend, the co-host for the Maintenance Phase podcast and the author of two books, “You Just Need to Lose Weight” and 19 Other Myths about Fat People and What We Don’t Talk About When We Talk About Fat. Gordon’s writing critically examines the messaging around health, wellness and weight, particularly in the social and cultural environment in the United States. She writes in the introduction of What We Don’t Talk About When We Talk About Fat, “...fat people face overwhelming discrimination in employment, healthcare, transit, the treatment of eating disorders, and more.” (Gordon, pg. 5, 2020)

Gordon describes her body of work as fat justice which is distinct from body positivity. She acknowledges the benefits of the body positivity movement, but also notes that like many mainstream movements, it leaves the more marginalized members behind. “Acceptance is a step forward, but it’s a far cry from centering fat people’s humanity in our cruel and ceaseless conversations about fat bodies.”(Gordon, pg. 7, 2020)

What We Don’t Talk About When We Talk About Fat is a text that is accessible to many readers. Gordon uses a strong personal voice in each chapter. By drawing on her memories and experiences as a fat person, she shows the cruelty she and others face because of their weight. From those anecdotes, she extrapolates broader messages around weight and fatness and how those messages harm people in larger bodies. 

In the chapter ‘First, Do No Harm’ Gordon opens with a story about a negative medical appointment, one of many such disappointing appointments she experienced whenever she sought medical care. The chapter starts with the line “I was twenty-six years old the last time I saw a doctor.”(Gordon, pg. 139, 2020) From there, Gordon lays out what brought her to the doctor, the anxiety she experiences prior to her appointment and the defense mechanisms she relies on to endure the encounter. Near the end of the visit, Gordon describes a terse exchange where the doctor suggested she lose weight in response to her diagnosis of an ear infection. “He glared for a moment, heaved another sigh, then left, his door slam thwarted by the muted, slow work of the door’s quiet hinge. We were both frustrated, and neither of us got what we were looking for.”(Gordon, pg. 140, 2020) To contrast this opening story, she ends the chapter with a more recent appointment that was both cathartic and revelatory. “All the years of effort, all the machinations to avoid humiliation and erasure, and someone had finally noticed. Later that day, I realized that despite years of trying, no one had ever told me that I cared about my health. And I did. I do.” (Gordon, pg. 153, 2020)

Gordon also cites extensive research to support her claims in the book. She cites academic journals such as BMC Medicine, Journal of the American Academy of Nurse Practitioners and the American Journal of Preventive Medicine. She also pulls information from mainstream news and media outlets such as pop culture shows like Law & Order, The New York Times, Allure Magazine and the Chicago Tribune. As Gordon writes in the opening chapter, this book is “a mix of memoir, research, and cultural criticism…” (Gordon, pg. 4, 2020) The analysis in the book provides a much more complex portrayal of weight, dieting and weight stigma than what is often presented in mainstream media or in virtual spaces. 

What We Don’t Talk About When We Talk About Fat is a challenging, but worthwhile read. Gordon confronts common and harmful myths about weight and people living in larger bodies. She ties her work with the broader theme of body autonomy and her book ends on a hopeful note as she imagines a world that is not obsessed with weight loss or harmful dieting messaging. “I also believe that my life is worth living, worth embracing, worth loving, and celebrating. And it’s worth all of that now–not two hundred pounds from now.” (Gordon, pg. 161, 2020) For some readers, this book may be an introduction to concepts such as Health At Every Size, fat liberation, universal design and other ideas. For other readers, Gordon’s book may be an affirmation of their own lived experiences and a source they can rely on when engaging in these conversations with the people in their lives. Though this book is short, it is packed with information that will encourage you to reflect on the impacts of diet culture and how we can build a more holistically healthier society.

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Intersex-Inclusive Progress Pride Flag
Image by Neo_Artemis from Pixabay

As Pride Month 2024 draws to a close, we want to take this opportunity to look back at some of our favorite LGBTQ+ blog posts. Whether you’re new to Himmelfarb Library or have been following our blog for years, this retrospective look at Himmelfarb’s Pride posts can serve as an opportunity to reflect on the history of Pride, celebrate the progress that’s been made towards LGBTQ+ equality and those who have fought for this progress, and recommit to the work that still needs to be done.

LGBTQ+ History

Most people don’t associate October with Pride Month, but October is LGBTQ History Month. In an October 2023 post titled The History Behind LGBTQ History Month, we took a look at the history behind LGBTQ History Month starting from its origins in 1994 when high school history teacher, Rodney Wilson addressed a lack of LGBTQ representation in school curriculum and worked with organizations such as the Human Rights Campain to have LGBTQ History Month recognized at the national level. October has additional significance within the LGBTQ community as the first March on Washington for Lesbian and Gay Rights took place in October of 1979, and a second March on Washington took place on October 11, 1987. In 1988, October 11th was recognized as National Coming Out Day. If you’d like to learn more about the 1979 and 1987 March on Washington for Lesbian and Gay Rights, read the full post!

LGBTQ+ Profiles

At GW, we are lucky to have many influential members of the LGBTQ+ community who have been members of our faculty for many years! We’ve profiled some prominent GW faculty and one prominent national figure on our blog.

Picture of Dr. Deyton and Dr. Fauci standing in front of a GW Medicine & Health Sciences logo.
(GW SMHS Facebook Page, 2017)

In June 2021, we posted a piece titled “Just Speak:” Lawrence “Bopper” Deyton. This in-depth profile of Dr. Deyton explores an influential experience Dr. Deyton had as a patient that would have a profound impact on the course of his career and inspire him to work to be a positive influence for change within the field of medicine and healthcare for his entire career. In 1978, Dr. Deyton co-founded what is now Whitman-Walker Health as “a health clinic for gay men and lesbians before AIDS redefined everything and the clinic became a hub for HIV treatment” (Sullivan, 2011). After attending medical school at GW and completing his residency at the University of Southern California Los Angeles County Medical Center, Dr. Deyton began working at the NIH, where he became friends with Dr. Anthony Fauci, and together they would play a crucial role in HIV/AIDS research during the early 1990s epidemic. Dr. Deyton was instrumental in overseeing the “clinical research on the development and approval of antiretroviral drugs and treatment strategies, including the first trials of combination therapies, the cornerstone of current HIV treatments” (GW SMHS, 2017). Read the full post to learn more about Dr. Deyton’s fascinating and impactful career!

Picture of Dr. Carlos Rodriguez-Diaz.

In September of 2021, we posted a profile titled Dr. Carlos Rodriguez-Diaz: Aim for What You’re Passionate About. In this post, Dr. Rodriguez-Diaz discusses what inspired him to go into public health and get involved with HIV care and prevention. He discusses the privilege of being a “young Latino gay man and to have access to education and contribute to my community by engaging in public health training, practice, and research” (Puro, 2021).

Dr. Rodriguez-Diaz talks about how he ended up at GW, what lessons scientists can learn from the spread of misinformation related to the COVID-19 vaccine, and how to make research more transparent and accessible. Included in his answer, he explains that “we should facilitate those scientists from minority populations (e.g. Latinos, Black, LGBTQ, Native Americans) to have access to mass media and platforms to reach out to their communities. No one else can speak to a community like a community member” (Puro, 2021). Read the full article to learn more about Dr. Rodriguez-Diaz.

In June of 2021, our post titled PRIDE: Dr. Rachel Levine: Physician and LGBTQ+ Health Advocate profiled Dr. Rachel Levine, the first openly transgender woman to be confirmed for federal office by the United States Senate in 2021. Dr. Levine is still serving as the 17th Assistant Secretary for Health (ASH) at the Department of Health and Human Services. Dr. Levine served as the Pennslyvania Physician General from 2015 to 2018, during which time she was responsible for an initiative that allowed law enforcement agents to carry Naloxone, an anti-overdose drug, and also allowed Pennsylvanians to purchase Naloxone from a pharmacy without a prescription. Levine has used her platform to highlight health inequality issues impacting marginalized communities, including the LGBTQ+ community. In a 2020 interview with Philadelphia magazine, Dr. Levine said “One of my goals, being a state health official…is that people will see me. … it’s about letting people put a face to something they might not understand, so they aren’t fearful, so that they don’t get angry, so that it doesn’t lead to hate.” 

Picture of Dr. Rachel Levine standing in front of a podium and US flag.

Resources

We’ve also posted about LGBTQ+ resources and local organizations. A 2023 post titled Celebrate Pride: LGBTQ+ Healthcare Resources highlighted selected books, journals, and streaming videos that are part of Himmelfarb’s collection. A more recent post from earlier this month titled Pride in the Collection shared more books from our Diversity and Disparities in Health Care collection relevant to the LGBTQ+ community. 

References:

George Washington University School of Medicine & Health Sciences. (June, 12, 2017). Lawrence “Bopper” Deyton installed as Murdock Head Professor of Medicine and Health Policy. SMHS News. https://smhs.gwu.edu/news/lawrence-%E2%80%9Cbopper%E2%80%9D-deyton-installed-murdock-head-professor-medicine-and-health-policy

Puro, A. (2021, September 29). Dr. Carlos Rodriguez-Diaz: Aim for what you’re passionate about. Himmelfarb Library Blog. https://blogs.gwu.edu/himmelfarb/2021/09/29/dr-carlos-rodriguez-diaz-aim-for-what-youre-passionate-about/

Sullivan, P. (2011, September 7). Lawrence Deyton, award nominee, heads FDA campaign against smoking. The Washington Post, https://go.openathens.net/redirector/gwu.edu?url=https%3A%2F%2Fwww.washingtonpost.com%2Flocal%2Flawrence-deyton-award-nominee-heads-fda-campaign-against-smoking%2F2011%2F08%2F15%2FgIQABsMYAK_story.html

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Background with a red, black, and green stripe. The word "Juneteenth" in the center.
Image by Wynn Pointaux from Pixabay

June 19th is Juneteenth, also known as “Black Independence Day,” “Freedom Day,” or “Emancipation Day.” Although President Abraham Lincoln issued the Emancipation Proclamation in 1863, enslaved people living in Confederate states, specifically Texas, would not learn of their freedom until two months after the Civil War ended in April of 1965. On June 19, 1865, Union General Gordon Granger and his soldiers arrived in Galveston, Texas, and informed the state’s residents that slavery had been abolished and that enslaved people were now free. Mary Elliot, Curator of American Slavery at the National Museum of African American History and Culture stated that “although there were enslavers who were aware of the implementation of the Emancipation Proclamation, it wasn’t until June 19th, 1865 that it was enforced with the Union Army” (Smithsonian Institution, n.d.).

While Juneteenth has long been a celebration of hope and freedom within the African American community, Juneteenth did not become a federally recognized holiday until 2021 when President Joe Biden signed the Juneteenth National Independence Day Act. If you’re interested in learning more about the history of Juneteenth, read our Understanding and Honoring Juneteenth post from last year.

Juneteenth and the Health Sciences

So how is Juneteenth related to medicine, the health sciences, and public health? In many ways, Juneteenth is more relevant than ever considering the focus in recent years on confronting health inequities and the structural racism that is at the root of those health inequities. In 2020, The American Medical Association (AMA) declared that racism threatens public health and created a strategic plan to advance health equity. The 2020 statement recognizes that “when race is described as a risk factor, it is more likely to be a proxy for influences including structural racism than a proxy for genetics” (O’Reilly, 2020). Race has long been considered a risk factor for many conditions and “is present in numerous clinical guidelines and algorithms” and “can impact medical decision-making that potentially worsens health disparities” (The Oregon Clinic, 2021). 

Juneteenth has many lessons that medical, nursing, and public health professionals and students can apply to further the cause of health equity and provide high-quality care to patients. Practicing critical reflection, “the process of identifying, questioning, and assessing deep-seated assumptions upon which our beliefs are built”  can help us “better recognize and arrest our biases that can manifest in our interpersonal encounters with patients, colleagues, and trainees” (Opara, et al., 2021). Participating in “transformational conversations” can help “raise the consciousness within the spaces we occupy” and bring important issues to light so they can be addressed (Opara, et al., 2021). 

Further Reading

Educating yourself on racial health disparities is always a great first step. Here are titles from our Diversity and Disparities in Health Care Collection that may be of interest:

References: 

Smithsonian Institution. (n.d.). What is Juneteenth? National Museum of African American History and Culture. https://nmaahc.si.edu/explore/stories/what-juneteenth

Opara, I.N., Lewis, C., Kasozi, R.N., Givens, R. (2021). Lessons from 1865: What clinicians can learn from Juneteenth. Passion in the Medical Profession. https://closler.org/passion-in-the-medical-profession/lessons-from-1865-what-clinicians-can-learn-from-juneteenth

O’Reilly, K.B. (November 16, 2020). AMA: Racism is a threat to public health. American Medical Association website. https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health

The Oregon Clinic. (June 18, 2021). Juneteenth and healthcare. The Oregon Clinic Newsroom. https://www.oregonclinic.com/newsroom/juneteenth-and-healthcare/

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one person's hand holding another person's hand

June is Cancer Survivors Month. Any cancer diagnosis induces feelings of anxiety, uncertainty and fear in patients. While novel approaches to and treatments for cancer are improving survival rates, social determinants of health continue to exert significant impact on patients’ ability to experience positive outcomes to treatment. Let’s look at one of these determinants, economic stability, in the context of cancer survival.

The term “cancer-related financial toxicity” was introduced in 2013 by Zafar and Abernethy, and described as, “the patient-level impact of the cost of cancer care” (Zafar and Abernethy, 2013). Even those patients who are privately insured are not protected from financial toxicity, as a 2022 study published in the Journal of the National Cancer Institute found. Out-of-pocket expenditures by privately-insured cancer patients in the United States have increased, due to the rise in high-deductible insurance plans and greater expected patient contribution to medical expenses (Shih et al, 2022).

How best, then, to help patients navigate the potential financial burdens of a cancer diagnosis, and thereby improve their potential treatment outcomes? A 2023 scoping review in Critical Reviews in Oncology/Hematology examined interventions for financial toxicity among cancer survivors. The interventions discussed include: financial navigation, which includes identifying patients at high risk for financial toxicity, offering guidance on out-of-pocket costs, and facilitating access to programs to alleviate financial stress. Financial counseling helps patients access advice and guidance on managing financial toxicity caused by cancer treatment. Insurance education entails providing patients a structured way to develop insurance literacy and assistance in choosing a plan. Other types of interventions examined included multidisciplinary psychosocial supports, intensive symptom assessments, and supportive care (Yuan et al, 2023).

The effectiveness of the interventions, researchers found, were closely tied to the causes of the cancer-related financial toxicity, with socioeconomic and employment status, cancer stage, and type of treatment, type of insurance, as well as coping skills all having a direct impact on how effective financial interventions could be. Looking closely at just one of the interventions mentioned above, engaging with financial navigation helped cancer patients save significant dollar amounts annually by facilitating the procurement of free medication, and insurance premium and co-pay assistance.

The financial interventions described in the evidence reviewed differed greatly, but more generally, the recent focus in the literature on finding ways to alleviate financial toxicity frequently faced by cancer patients is one promising step towards improving outcomes for all patients dealing with cancer.

References

Debela, D. T., Muzazu, S. G., Heraro, K. D., Ndalama, M. T., Mesele, B. W., Haile, D. C., Kitui, S. K., & Manyazewal, T. (2021). New approaches and procedures for cancer treatment: Current perspectives. SAGE open medicine, 9, 20503121211034366. https://doi.org/10.1177/20503121211034366

Lau, L. M. S., Khuong-Quang, D. A., Mayoh, C., Wong, M., Barahona, P., Ajuyah, P., Senapati, A., Nagabushan, S., Sherstyuk, A., Altekoester, A. K., Fuentes-Bolanos, N. A., Yeung, V., Sullivan, A., Omer, N., Diamond, Y., Jessop, S., Battaglia, L., Zhukova, N., Cui, L., Lin, A., … Ziegler, D. S. (2024). Precision-guided treatment in high-risk pediatric cancers. Nature medicine, 10.1038/s41591-024-03044-0. Advance online publication. https://doi.org/10.1038/s41591-024-03044-0

Shih, Y. T., Xu, Y., Bradley, C., Giordano, S. H., Yao, J., & Yabroff, K. R. (2022). Costs Around the First Year of Diagnosis for 4 Common Cancers Among the Privately Insured. Journal of the National Cancer Institute, 114(10), 1392–1399. https://doi.org/10.1093/jnci/djac141

Yuan, X., Zhang, X., He, J., & Xing, W. (2023). Interventions for financial toxicity among cancer survivors: A scoping review. Critical reviews in oncology/hematology, 192, 104140. https://doi.org/10.1016/j.critrevonc.2023.104140

Zafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncology (Williston Park, NY). 2013;27(2):80-149.

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A piece of wrinkled shaded with the colors of the rainbow

Every person is different, and that diversity makes human beings so fascinating. In order to serve diverse populations, it’s important for us here at Himmelfarb Library to have a wide variety of materials for students to learn from. One of these populations is the LGBTQ+community. 

To help students locate material related to diverse populations, we have a Diversity and Disparities in Health Care collection. This collection covers a wide range of unrepresented groups, including queer people. Given the wide variety of content we offer, it would be impossible to cover everything in one blog post (which is a good thing). Instead, here are a few books from our collection to give readers a glimpse of what the library has to offer.


Global LGBTQ Health: Research, Policy, Practice, and Pathways.

By: Hwahng, Sel J. editor.; Kaufman, Michelle R. editor.

This book takes a look at the intersection of global and LBGTQ+health. Aiming to take a larger look at LGBTQ+health across the world, this text offers insight into issues on both a regional and global scale. 

The case against conversion "therapy": evidence, ethics, and alternatives

Haldeman, Douglas C., editor.

While many states have now banned the practice known as “conversion therapy” there are still places where it is used, often on LGBTQ+ youth. This text takes a look at the motivations behind the practice, the decades of evidence showing it to be actively harmful, and why LGBTQ+identities are not something to be “cured” but embraced. 

Trans medicine: The emergence and practice of treating gender

Shuster, Stef M., author.

This text covers both the history and contemporary practice of Trans medicine. Medicine for transgender people is often misunderstood due to both a lack of knowledge and misinformation. In this book, readers can not only learn that Trans medicine is not new, but is backed by decades of science.

Bodies and barriers: Queer activists on health

Shanker, Adrian, editor.; Levine, Rachel Leland, 1957- writer of foreword.; Kendell, Kate, writer of afterword.

Health disparities can exist for a variety of reasons. In this text, multiple queer activists explain some of the factors that lead to such disparities, what negative outcomes result, and ideas on how to fix them. 

The script - queer futures

Wortham, J., film producer.; Fryer, Brit, film director.; Schamus, Noah, film director.; Multitude Films, production company.; Good Docs (Firm), distributor

Our last resource for this post is a film. Using recreations of personal interviews, this film takes a look at how transgender and nonbinary people interact with the medical system, and how practitioners and patients interact with one another.

References:

Haldeman DC, ed. The Case against Conversion “Therapy”: Evidence, Ethics, and Alternatives. American Psychological Association; 2022.

Hwahng SJ, Kaufman MR, eds. Global LGBTQ Health: Research, Policy, Practice, and Pathways. First edition. Springer; 2024. doi:10.1007/978-3-031-36204-0

Shuster SM. Trans Medicine: The Emergence and Practice of Treating Gender. New York University Press; 2021.

Shanker A, ed. Bodies and Barriers: Queer Activists on Health. PM Press; 2020.

Wortham J, Fryer B, Schamus N. The Script - Queer Futures. [Distributed by] GOOD DOCS; 2023.

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Three male doctors in white coats in a black and white photo taken in 1892
Dr. William Coley (center), public domain photo from https://commons.wikimedia.org/wiki/File:William_Coley_1892.jpg

May is Melanoma Awareness Month, which serves as an annual reminder to visit a dermatologist regularly for a skin check. Melanoma affects every skin tone. Visit Himmelfarb's collection, Diversity in Dermatology, to explore our library resources on this topic.

This year, let’s go back in time to learn about the origin of one tremendous contemporary advance in the treatment of malignant melanoma -- immunotherapy -- and learn about a new development coming for patients diagnosed with melanoma.

Dr. William Coley (1862-1936) was a bone surgeon and cancer researcher who spent his career at the New York Cancer Hospital. At the time, cancers were commonly treated with amputation. Coley’s young patient, 17 year old Elizabeth Dashiell, presented with an aggressive sarcoma in her hand. Despite an amputation, her cancer had metastasized and she died ten weeks later. Coley began to comb through hospital records, and found a patient who had had four recurrences of an inoperable sarcoma, whose disease had gone into remission when he developed a superficial streptococcal infection of the skin. Coley managed to locate the patient, who did not present with any clinical evidence of malignancy. He also found a number of observational publications connecting this particular skin infection with positive outcomes for sarcoma patients.

Cover of a medical monograph from 1914
The Treatment of Malignant Inoperable Tumors, by William B. Coley, MD (1914)

Coley began intentionally inducing this skin infection in his cancer patients, despite the fact that antibiotics were not yet available to help control infections. His practice is of course shocking and unethical in the light of our contemporary understanding of medical ethics. Additionally, the specific infection, erysipelas, was difficult to induce in patients, some of whom never developed the infection, and some of whom were injected repeatedly in the attempt to induce it. Having achieved some results with his initial attempts, Coley began using a heat-killed version of the infection, combined with one other toxin (which is known to us today as Serratia marcescens) to increase the virulence, and in turn, patients’ immune responses. This combination came to be known as “Coley’s toxins.” A summary of the patients treated with Coley’s toxins prior to 1940 shows that 22 soft-tissue sarcoma patients and 8 lymphoma patients were found to be free of clinical evidence of disease for a period of at least 20 years. (Starnes, 1992). Results for other types of cancers varied, but were not nearly as dramatic. You can read Coley’s 1914 report on his treatment of patients with toxins in its entirety online.

The concept of inducing an immune response in patients to address malignancies also underlies the pioneering work done by contemporary researcher James Allison, for which he shared the 2018 Nobel prize with Tasuku Honjo, for their work on immunotherapy. Allison’s work is chronicled in the documentary Breakthrough, which is available to stream on a number of platforms. Immune checkpoint therapy stimulates the patient’s immune system by blocking inhibitory checkpoints, in order to enable T cells to attack the tumor. Currently, immune checkpoint inhibitors which target the molecules CTLA4, PD-1, and PD-L1 are approved. The very first immune checkpoint therapy, ipilimumab, was approved in 2011 for the treatment of melanoma; since then, seven additional immune checkpoint inhibitors have been approved for use in the treatment of an ever-increasing number of cancers.

Research is ongoing towards the development of melanoma vaccines, which also build on the basis of activating patients’ own immune systems. The April 2024 issue of Cancer Research contains a brief comment on the growing body of evidence for vaccines tailored to specific tumor mutations, noting that progress has accelerated and increased during the past five years. (Fritsch & Ott, 2024) 

While the ultimate goal is to prevent patients from developing melanoma in the first place, the results of research are leading to exciting and unprecedented outcomes for patients who have the disease. Dr. Coley’s early work with the immune system of cancer patients reminds us that pioneering ideas may come before their time and before the technology exists to support them, but may nonetheless lead to unimaginable and positive outcomes centuries later.

References

Coley, W. B. The Treatment of Malignant Inoperable Tumors with the Mixed Toxins of Erysipelas and Bacillus Prodigiosus : With a Brief Report of 80 Cases Successfully Treated with the Toxins from 1893 to 1914 / by William B. Coley. M. Weissenbruch, 1914; 1914.

Fritsch, E. F., & Ott, P. A. (2024). Personalized Cancer Vaccines Directed against Tumor Mutations: Building Evidence from Mice to Humans. Cancer research, 84(7), 953–955. https://doi.org/10.1158/0008-5472.CAN-24-0565

Starnes C. O. (1992). Coley's toxins in perspective. Nature, 357(6373), 11–12. https://doi.org/10.1038/357011a0

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Going to the doctor can be an anxiety-inducing experience. Regardless of how comfortable one is with their medical provider, the prospect of test results bearing bad news can make a routine visit understandably nerve-wracking. 

But what if one’s apprehension regarding medical care was due to other reasons? What if going to the doctor meant being called the wrong name and pronouns for the entire visit? What if your visit led to being grilled about your life and hobbies as if they’re to blame for whatever ails you? What if you had to change how you looked or dressed to get treatment?

Sadly, these experiences are not uncommon for adults who identify as LBGT. According to a new survey out of the Kaiser Family Foundation (KFF), one third of adults who identify as LBGT have experienced discrimination when they are treated by a health care provider. Negative experiences included but were not limited to:

  1. A provider assuming something about them without asking (1).
  2. A provider implying or suggesting they were to blame for a health problem (1).
  3. A provider ignoring or rejecting a request or question (1).

These negative experiences make patients less likely to seek care and can impact their health as a result. Even when LBGT adults continue to seek care despite these negative experiences, discrimination can lead to increased levels of anxiety or distress, which in turn can contribute to mental health conditions like depression or anxiety. Given that 46% of  LBGT adults report being unable to receive mental health services when they needed them in the last three years, this only worsens existing issues (1). 

LBGT patients are people, just like anyone else. Thankfully, there are things practitioners can do to provide a more welcoming attitude to  LBGT patients. 

  • Don’t assume one’s legal name and gender markers are what they use. Ask patients what they wish to be called by and what pronouns they want you to use. 
  • Don’t make assumptions: Never assume something about a patient just because they are LBGT. 
  • Have material in your office or medical facility that identifies your practice as a safe space. This can include patient materials about health concerns that disproportionately impact LBGT individuals, having a private policy on display, and showcasing rainbow stickers or signs that state the area is a safe space (4). 
  • Ensure your intake forms are inclusive. There are examples online one can use as templates like those available from Queering Medicine (3). 
  • Explicitly use inclusive language and images both in the office and on all social media. 

As pride month approaches, let’s work to ensure medicine is welcoming to all our patients, regardless of who they are. 

1.Survey: LGBT Adults Are Twice as Likely as Others to Say They’ve Been Treated Unfairly or with Disrespect by a Doctor or Other Health Care Provider. KFF. Published April 2, 2024. Accessed May 20, 2024. https://www.kff.org/racial-equity-and-health-policy/press-release/survey-lgbt-adults-are-twice-as-likely-as-others-to-say-theyve-been-treated-unfairly-or-with-disrespect-by-a-doctor-or-other-health-care-provider/

2. Queering Medicine - Intake Form Guidance for Providers. Queering Medicine. Published July 8, 2021. Accessed May 20, 2024. https://www.queeringmedicine.com/resources/intake-form-guidance-for-providers

3.  Daniel H, Butkus R. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med. 2015;163(2):135-137. doi:10.7326/M14-2482

4. Bourns A, Kucharski E, Peterkin A, Risdon C, eds. Caring for LGBTQ2S People : A Clinical Guide. Second edition. University of Toronto Press; 2022.

Published on
Fingers with arthritis resting on a blue cushion
Fingertip arthritis - DIP joint, by handarmdoc on Flickr, licensed under Creative Commons

May was designated as Arthritis Awareness Month by Congress and the President in 1972. An estimated 53.2 million US adults (21.2%) reported being diagnosed with some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia, in response to the CDC’s National Health Interview Survey (Fallon et al., 2023). There are numerous types of arthritis. Because of its prevalence, as well as the financial impact of the various forms of arthritis – for the year 2017, the CDC estimated that osteoarthritis was the second most costly condition treated at US hospitals. Let’s look at a couple of recently published articles examining the impacts of arthritis on population health.

When we consider a condition that is as common within the population as arthritis, and as costly to treat, health disparities are a concern. In a brief report in the July 2023 issue of Arthritis Care & Research, researchers examined healthcare utilization by patients diagnosed with rheumatoid arthritis (RA) or osteoarthritis (OA), focusing on whether these patients live in rural/isolated, largely rural, or urban locations (Desilet et al., 2023) The study was based on questionnaires filled out by over 37,000 RA patients and over 8200 OA patients. A majority of the RA patients responding (74.5%) lived in a rural area, and this proportion was similar for OA patients. By analyzing questionnaire responses indicating healthcare utilization over six months, the research team found that among RA patients, urban residents were more likely to utilize healthcare provided by some type of professional than their rural counterparts. The same was true for OA patients. Patients with both types of arthritis fare better under the care of a rheumatologist, and in rural areas, access to this expertise is more limited. The findings of this study suggest the importance of extending access to rheumatology care in rural communities that are not currently well-served.

A forthcoming article in the journal Rheumatology (d'Elia et al, 2024) reports on a study of symptoms in a primary care database, which tracked prodromal (early) symptoms for the 24 months prior to diagnosis, in over 70,000 RA patients, over a period of 18 years. When analyzed demographically and socioeconomically, the findings were that symptoms were reported differently in new-onset RA across ethnic groups. While some of this may be accounted for due to the way symptoms are reported by patients, delayed diagnosis and treatment is another potential factor. 

Another interesting finding of this study was the fact that of the symptoms reported, there was a discrepancy between the most common symptoms of RA (e.g. painful small joints of the hands, present in over half of RA patients) and the percentage of patients in the database who were reporting this symptom (10.2%). This may point to under-coding of symptoms, which would have an impact on treatment. Future studies may build on these findings delving more deeply into the differences in RA symptoms among different ethnic groups, including their underlying causes and their clinical implications.

Arthritis affects a large proportion of the population in the US and worldwide, and the burden falls more heavily on those who struggle to access care, as well as those who are not served equitably within healthcare settings. This Arthritis Awareness Month, consider how you might be able to contribute to our understanding of these disparities and help to cure them.

References

Fallon, E. A., Boring, M. A., Foster, A. L., Stowe, E. W., Lites, T. D., Odom, E. L., & Seth, P. (2023). Prevalence of Diagnosed Arthritis - United States, 2019-2021. MMWR. Morbidity and mortality weekly report, 72(41), 1101–1107. https://doi.org/10.15585/mmwr.mm7241a1

Desilet, L. W., Pedro, S., Katz, P., & Michaud, K. (2023). Urban and Rural Patterns of Health Care Utilization Among People With Rheumatoid Arthritis and Osteoarthritis in a Large US Patient Registry. Arthritis Care & Research (2010). https://doi.org/10.1002/acr.25192

d'Elia, A., Baranskaya, A., Haroon, S., Hammond, B., Adderley, N. J., Nirantharakumar, K., Chandan, J. S., Falahee, M., & Raza, K. (2024). Prodromal symptoms of rheumatoid arthritis in a primary care database: variation by ethnicity and socioeconomic status. Rheumatology (Oxford, England). Advance online publication.

Published on
An image from NAMI (the national alliance on mental illness) that says "small steps can lead to big progress in mental health"

When we talk about illnesses, one of the many things that might first come to mind is symptoms. A friend complains about a sore throat, a fever and white patches on the tonsils? We might advise them to go see a doctor about a strep test. A child complains of a headache and starts sporting a rash made of tiny red dots? It wouldn’t be outrageous to consider chicken pox the culprit. Of course, disease presentation can vary and many illnesses share symptoms, but at the end of the day, many illnesses provide a visible clue that something is wrong. 

Mental illness is far less visible to the naked eye. There is no rash that accompanies depression, nor is there a wheezing cough that comes with anxiety. The symptoms of mental illness, as the name implies, are often found in thought patterns and behaviors of those who have them. And while these thought patterns and behaviors can be observed, it often far more than a passing glance to properly diagnose someone. The average delay in treatment after a person starts showing symptoms of a mental illness is 11 years (1). 

Just because the symptoms of mental illness might not be as clear as other illnesses, they are just as debilitating. 

While mental illness may be hard to spot, that doesn’t mean it isn’t common. While one in five adults in the United States experience mental illness, only half of them receive treatment (1). The statistics for children are even more dire: nearly 70% don’t receive treatment (2).  

Treatment in itself is often difficult to access, with long wait lists to see a provider and spotty insurance coverage among other issues. 

To help raise awareness about mental illness, May is Mental Health Awareness Month. The National Alliance on Mental Illness (NAMI) is celebrating with the campaign “Take the Moment” which aims to highlight programs NAMI provides for patients and their loved ones dealing with mental illness, as well as working to erase stigma around mental health. Here at GW, our Resiliency and Well-Being Center has its own list of topics it will be discussing both this month and the month of June.

  1. Mindfulness and Stress Management (May 8-21)
  2. Healthy Eating (May 22 - June 4)
  3. Restorative Sleep (June 5-18)
  4. Physical Activity: Improving Movement  and Exercise (June 19 - July 2)

The center will also be offering classes about practicing mindfulness both online and in person. 

Here are some ways you can decrease stigma around mental illness: 

  • Language really matters. Terms like “bipolar” and “OCD” can be thrown around as slang for being “moody” or “neat” respectively, despite being terms for serious mental conditions. Don’t perpetuate stigma and stereotypes about these conditions: use different words rather than conditions to describe what you mean. 
  • Reach out to others: It’s okay to need help. If you haven’t been feeling well, you can find help. The school’s Resiliency and Well-Being Center provides resources to support those who are coping. There are also plenty of national resources one can use: NAMI offers a variety of resources in-house and also curates outside resources for those who either need help or want to help someone else.
  • Know mental health is for everyone: stigma about mental health implies that those who have mental illness are simply “not trying hard enough” or “seeking attention.” This couldn’t be further from the truth: mental health conditions are caused by a variety of factors including genetics and environment.  

1. Mental Health Awareness Month. NAMI. Accessed May 6, 2024. https://www.nami.org/get-involved/awareness-events/mental-health-awareness-month/

2. House TW. A Proclamation on National Mental Health Awareness Month, 2024. The White House. Published April 30, 2024. Accessed May 6, 2024. https://www.whitehouse.gov/briefing-room/presidential-actions/2024/04/30/a-proclamation-on-national-mental-health-awareness-month-2024/

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