• Guest Editorial

    Integrating Primary Care, Public Health for Health Equity

    A Journey in Five Chapters

    March 21, 2022, 4:31 p.m. Laura Chanchien Parajón, M.D., M.P.H. — The winner of the 2021 AAFP Public Health Award shares highlights from her journey in primary care and public health. Nominations for the 2022 Public Health Award are open through April 30. See the sidebar below to learn more.

    Chapter One: Staying Invisible Was Not an Option

    My dad came to the United States from Taiwan as a physician in the 1960s when immigration quotas for Asians were loosened to address the physician shortage here in the States. My dad practiced in the same community for 50 years as a primary care doctor. I got to work with him for two years and learned valuable life lessons. “Smiles are free” and “Listening, being humble and practicing kindness is often better than any medicine” were some of the things he’d always say. Seeing my dad’s joy and commitment to serving his patients is the reason I chose a career that emphasizes primary care. 

    Health Equity sign with clouds and sky background

    He also warned us about anti-Asian racism, and that to survive in America, we should keep our heads down and try to stay invisible. But my dad didn’t realize that some of my earliest memories came from being bullied on the playground for being Asian and being told to go back where I came from, even though I was born here and spoke perfect English.

    These experiences made me sensitive to injustices, and they’re part of the reason I went into public health and health equity work. The more I saw, the more I knew that I didn’t want this for my own children and other children. I recognized that being invisible would not be an option for me — especially when people of color continue to experience sharp economic and social inequities and the continuing impact of structural racism.

    Chapter Two: Discovering a Health Equity Framework

    In college, I discovered the 1978 Declaration of Alma-Ata, the aspirational World Health Organization document on primary health care that defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” and as “a fundamental human right.”

    After 40 years of data and experience with primary health care the WHO reaffirmed its approach in 2018 with the Astana Declaration.

    As the foundation for improving health equity, the resulting primary health care strategy expanded from the traditional biomedical focus on health services to a comprehensive approach designed to achieve health and well-being for all people. This comprehensive approach to PHC has three key pillars:

    1. integrated health services to deliver quality care and public health services;
    2. multisectoral policies and action to address the root causes of poor health, including structural racism and social determinants of health; and
    3. having empowered people and communities who actively engage as partners to improve health services and health outcomes (a concept also known as community empowerment).

    Health equity, which has been defined as “striving to equalize opportunities to be healthy,” is a social justice approach to address social determinants of health such as poverty, discrimination, poor education and lack of access to health care that comprise 80% of the causes of poor health.

    Growing evidence, especially in the global health world, has shown that tackling health equity requires a much greater emphasis on two of the elements of comprehensive PHC — effective partnering practices for multisectoral action, and empowered people and communities. A 2017 review of the implementation of comprehensive PHC demonstrated that this model can successfully reduce neonatal, child and maternal mortality rates.

    Chapter Three: Seeing Health Equity in Practice

    Despite the potential of comprehensive PHC for improving health equity, primary health care, especially in the United States, is still largely dominated by a gap between a biomedical focus on delivery of health care services to individuals versus a more comprehensive focus that includes community and population health.

    With the exception of the Indian Health Service, most primary care services in the United States are not integrated with public health, and many lack the organizational structure and staffing needed to adequately address the social determinants of health or to develop multisector and community-empowered partnerships. I thought that earning a public health degree would help me bridge this gap in my practice, but as a busy clinician, I quickly realized that my paid clinical responsibilities superseded any time I had set aside for community work — which seemed to live in the space of “underfunded afterthought” in the world of medicine.

    It wasn’t until I lived and worked as a medical missionary in rural Nicaragua several years ago that I saw how the WHO’s model of comprehensive primary health care could actually work. While not perfect, the government there worked to improve the health of rural and marginalized urban populations by increasing access to services through small health posts (facilities that deliver primary health care and work on health promotion and disease prevention) and mobile clinics. The government also increased the number of rural providers by developing medical and nursing schools that trained interprofessional teams in their own communities, and they aligned their health work with rural economic development programs, and increased access to electricity and cell phone service.

    Vaccine campaigns are performed during a three-week period when primary care doctors, nurses and community health workers fan out throughout the country to offer vaccination pods (where vaccines can be administered to large numbers of people in a short time) as well as door-to-door vaccinations. The work of comprehensive primary health care has resulted in significant improvements in maternal and child mortality rates, as well as some of the highest vaccination rates in the world.

    Chapter Four: Working Toward Health for All People

    The pandemic that has ravaged parts of the world for the past two years was an X-ray that exposed and exacerbated health inequities that existed long before anyone had heard of COVID-19. As we celebrate Women’s History Month, I am grateful to have worked with so many amazing women leaders here in New Mexico who led us and their organizations with compassion, inspiration, empathy and vision. There are too many to name, but I would especially like to recognize Carol Pierce, the director of community and family services for the city of Albuquerque, who led the COVID-19 response to prevent outbreaks and protect people experiencing homelessness; Tracie Collins, M.D., M.P.H., M.H.C.D.S., the state’s former health secretary, who led the rollout of COVID-19 vaccines with a focus on equity; Venice Ceballos, who led ou community health worker response for vaccine equity in our communities of color; and Gov. Michelle Lujan Grisham, who steadfastly guided the state’s COVID response alongside our current health secretary, David Scrase, M.D., using data to inform actions.

    At the same time, my heart goes out to economically disadvantaged women, especially women of color, who have had to continue working outside their homes as essential workers, despite many of them being paid minimum wage. They also have been more likely to lose their jobs or have had to leave their jobs to take care of their children. During Women’s History Month, we should think about how we can take the lessons we have learned from the pandemic to build back better.

    Chapter Five: Now is the Time

    As an Asian American physician and a woman of color, I find the increase in Asian American hate crimes and killings particularly discouraging in a time when I have never worked so hard to help our community. I fear for my family, and for other Asians who are experiencing increased hate crimes. I also fear for my Hispanic, Latino, Black and Native American brothers and sisters who continue to face disproportionate numbers of deaths from COVID due in large part to structural racism. Now is the time for family physicians to become more visible in our actions to serve our communities. Here are the first steps we can take:

    1. Support the AAFP’s position paper on the integration of primary care and public health. As family physicians, we can use this moment to band together to familiarize ourselves with this document, which gives us a roadmap of what comprehensive PHC could look like in the United States and shows what we can do together to work alongside communities to address long-standing root causes of health inequities, such as structural racism.
    2. Stay visible in the community. National vaccine surveys have demonstrated that health care professionals are the most trusted voice across politics, race and ethnicity. As family physicians, we can use our position in the community as a trusted voice to help build bridges in the community and link to public health to help address key community priorities.
    3. Invest in communities and get compensated for community time. Health systems should value and pay for the time that family physiciansother health workers and community membersspend to care for patient populations, not just for individual clinical care. Time spent working with communities to support their health priorities, training community health workers, mentoring students in the pipeline, or working to integrate and align with state and local health departments should all be compensated. We need strong advocacy in this area.

    The integration of primary care and public health is an ongoing process. It has taken decades for things to get this far, but there is a path that can lead us toward addressing health equity, overcoming barriers to care and ensuring that all patients get the care they deserve.

    Laura Chanchien Parajón, M.D., M.P.H., is the deputy cabinet secretary for the New Mexico Department of Health. In 2021, she was the recipient of the AAFP’s Public Health Award.