Two women, one Black and one white: Though the white woman has a higher lifetime risk of being diagnosed with breast cancer, the Black woman has a 41% greater risk of dying from the disease.
Two neighborhoods in Richmond, Virginia: In one, 5% of individuals live below the poverty line; in the other, 29%. Less than a mile separates the two neighborhoods. But in the first, life expectancy is 83 years, and in the second, 69.
These are just two sets from many statistics that illustrate the reality of health disparities in the United States. An issue recently brought into sharp focus by the unequal toll the coronavirus pandemic has taken on poorer Americans and communities of color, health disparities nevertheless are a long-existing problem, reflecting inequities long overdue for change, says Vanessa B. Sheppard, Ph.D.
“We can’t pretend to be a moral society and have one of the leading health care systems in the world, and have these disparities,” she says.
A leading expert in health disparities research, Sheppard is the Theresa A. Thomas Memorial Chair in Cancer Prevention and Control for the School of Medicine’s Department of Health Behavior and Policy. She also serves as VCU Massey Cancer Center’s associate director for community outreach engagement and health disparities.
The MCV Campus, Sheppard believes, is uniquely qualified to become a leader in understanding and addressing health disparities — particularly in cancer care and outcomes. As an advanced academic medical center but also as a safety-net provider for the area’s most vulnerable, VCU Health serves a broadly diverse patient population from the metropolitan area and nearby rural communities.
“We are so well-positioned,” she says, “to learn what factors are unique to the populations we serve and what may contribute to helping them to live longer and healthier lives.”
A commitment to research
Sheppard grew up in the Norfolk/Hampton Roads area of Virginia and, throughout her undergraduate and master’s programs, had an eye toward law school.
But a serious illness and her experiences — both good and bad — as a patient, along with the encouragement of a graduate school professor, led her to a Ph.D. at Old Dominion University, concentrating on community health. While completing her dissertation, she worked as a public health educator with Richmond Department of Health, focusing on early detection of breast and cervical cancers and then as a senior policy analyst at the state level.
That job, she says, affirmed a desire to contribute to the research that may inform policy, leading her to a postdoctoral fellowship in health services epidemiology at Eastern Virginia Medical School followed by a research fellowship through the Association of American Medical Colleges.
Joining the faculty at Georgetown University, she served as a tenured associate professor in the Department of Oncology and as assistant director of health disparities at the Lombardi Comprehensive Cancer Center. Though she loved her work at Georgetown, what drew Sheppard to VCU in 2016 was the opportunity to help expand and strengthen the focus on understanding, addressing and educating about health disparities in a safety-net medical center with a strong commitment to community.
“I had this sense,” she says, “that this was an opportunity to do something bigger than me.”
The toll of health disparities
Defining health disparities is simple, Sheppard explains: “It is when one group has a worse incidence, prevalence or outcome compared to another group.” A wide body of research consistently demonstrates that health disparities are disproportionately experienced by people from within historically disadvantaged demographic groups.
Black women in the U.S. suffer maternal mortality rates more than three times higher than white women. Indigenous American men have the highest risk for suicide. Adults without a high school degree have the highest rates of obesity. And the poorest Americans have higher incidences of heart disease, cancer, stroke, diabetes, childhood asthma, kidney and liver disease, and accidental death compared to wealthier Americans.
The growing recognition of the unequal health burden carried by some groups has brought increasing focus on the “why” behind these disparities, and particularly how social determinants of health drive health disparities. It’s a complex interplay of environmental, behavioral, socioeconomic, cultural, clinical, psychological and biological/genetic factors that shapes social determinants: everything from practical barriers to care, like lack of insurance coverage or transportation; to exposure to environmental pollutants; to the fact that disadvantaged populations are less likely to be represented in clinical trials.
As Massey Cancer Center Director Robert Winn, M.D., points out, “We know that ZIP code and the neighborhood where you live are much more predictive of how you are going to do in life than your DNA.”
He notes, for example, that high-poverty urban neighborhoods often are characterized by substandard housing, underperforming schools, limited job opportunities and lack of access to fresh food and safe outdoor green spaces for recreation. “If you set up the social structures so someone is disadvantaged already, then it’s no wonder they are at increased risk for poorer health,” Winn says.
Sheppard’s research, outreach and collaborative initiatives are working not only toward more comprehensive understanding of these kinds of determinants of health disparities — particularly in cancer care — but toward developing effective interventions to remediate those disparities in the communities the MCV Campus serves.
“It isn’t enough to do cutting-edge research if the people right around you can’t access it,” she says.
Sheppard has long been interested in the power of the patient-provider relationship to shape health outcomes. While at Georgetown, she pursued advanced training in understanding the connections between culture, health literacy and behaviors. Much of her research since then has been two-fold: How might perceptions and the decision-making process on the patient side of the relationship affect outcomes for African American, African-born and Latina breast cancer patients? And which patient-focused interventions can strengthen the effectiveness of that relationship?
“That patient-provider interaction, relationship and information exchange is so important, particularly in relation to cancer care,” says Sheppard, who emphasizes the care continuum of prevention, screening, diagnosis, treatment and outcomes.
Her research has found that patients’ perceptions of these encounters and the quality of communications with providers appear to influence how likely patients are to follow recommended treatment guidelines.
One intervention Sheppard developed in a pilot study at Georgetown, “Sisters Informing Sisters,” seeks to address lower uptake of chemotherapy and hormone therapy among African American breast cancer patients as compared with white patients. The intervention was designed to help newly diagnosed African American breast cancer patients make well-informed decisions about their care by pairing them with African American breast cancer survivor-coaches who have undergone similar therapies.
The pairs work though a guidebook of decision-support materials designed to prepare the newly diagnosed women to ask more questions and engage with their providers.
Based on the pilot study’s positive results showing better uptake of recommended therapies, the American Cancer Society has provided funding for an expanded five-year intervention study at VCU.
Leading the way
Expanding the portfolio of disparities-focused research – one of the goals Sheppard was tasked with when she arrived on the MCV Campus – is part of a larger and more holistic effort at the university to bring to the forefront the importance of understanding and addressing health disparities.
“As an urban hospital and urban university, and also as a provider of safety-net care, we have a commitment and responsibility to reduce health care disparities in our local and regional community and the commonwealth,” says School of Medicine Dean Peter F. Buckley, M.D.
Beyond research, as department chair Sheppard has brought in diverse, talented new hires and is building a team-based approach to research “where you might have a bench scientist, a social scientist and a clinician scientist coming together to address a problem.” With that approach, she believes, “We can chisel away at the multiple factors that contribute to disparities and the relationship among them.”
She places a high priority on mentorship and on fostering the careers of faculty, researchers and students. As the mother of twin teenage boys, she recalls the challenges of being a tenure-track academic, married with young children and no role models: “No one looked like me — a woman of color with kids — who made tenure.” So she particularly wants to model support and balance for her female faculty, co-leading a mentoring program to help them progress in their careers.
Buckley cites Sheppard’s emphasis on mentoring as one of her valuable contributions. “One thing I admire about her leadership is she puts forward and mentors her colleagues and her team and advances their work. That allows her to be a much more effective and synergistic leader and an advocate for health care disparities.”
Also, he notes, “In her own right, the scientific contributions she has been able to make and the changes that she has advanced in supporting cancer health care are important.” Sheppard’s growing national prominence as a researcher also raises the medical school’s profile and has made it possible to recruit other talented professionals.
Her vision is that VCU Health will become the nationally recognized leader in moving from health disparity to health equity in cancer research, treatment and care.
“People talk about ‘hard-to-reach populations’ in health care research. Because of the population we serve here, we can tackle some of the hard problems that lead to disparate outcomes related to race, ethnicity and socioeconomic status in our trials. We can tackle some of the hard problems of African Americans and cancer.
“We could be the experts, and if we find ways to improve outcomes for populations that consistently have been disadvantaged or have had higher burdens, then we could help everyone.”
She recognizes that the changes won’t come quickly — that the complexities underlying health disparities are only beginning to be understood and that reaching health equity will demand long-term systemic change.
But VCU, Sheppard believes, should lead the way. “We are going to be the model of applying the best care and most innovative research in the real world.”