'We Have to Do Better': Discussing Health Disparities with Dr. Ana Núñez
Ana E. Núñez, MD, is a professor of medicine and the associate dean of Diversity, Equity & Inclusion for the College of Medicine. Dr. Núñez is also the director of the National Center of Excellence in Women's Health and Women's Health Education Program. Her curricular expertise includes topics in sex and gender medicine, primary care, trauma/violence prevention and cultural competence.
How did you become interested in medicine?
My first interest was actually about teaching other people. I was interested even when I was about 4 years old in this drawing that my mom kept that was just a a stick figure teaching somebody something. I think it was a bit of foreshadowing in terms of the things that I would do as a physician. My mom was also a licensed practical nurse, so I had exposure to the medical field. My sister went to nursing school, so I heard that perspective as well.
Then in high school we had this biology course and one of the pieces of it was that we actually got to get into the hospital. I remember it like it was yesterday. We went into the room of this elderly lady and she was very still, sitting in the bed. Her complexion was sallow, and it was almost like her skin was sort of tightened, and her eyes just looked like the light of her life was being extinguished very slowly. They said she had metastatic cancer. And I just thought, ‘One cell misbehaving did this to this person. I need to know about that. I need to help with that. I need to figure out what this is about.'
Being a science nerd and being very interested in innovation, both the art and practice of medicine were appealing to me.
You mentioned being drawn from a really young age to teaching and to instruction, and plenty of DUCOM students have mentioned you to our office as a faculty member who has been a mentor for them. What draws you to teaching and to paying your experience forward with the current generation of medical students?
My mom has a very heavy accent and English is a second language for her, so by helping her with English, I got into a teaching role even as a little kid. I've always liked to understand things in order to explain them to others.
I also had educational experiences in medical school and during a medical education fellowship where I got to see how the stew is made, like, ‘Oh, that was why teaching a concept that way worked.' I think a piece of that is loving learners, but you also have to remember what it was like not to know what you know now.
To me, the physicians who are coming next are incredibly important in determining what the future will be. If I can contribute even a little bit to somebody in terms of their insight, their caring about a patient's experience and things like that, then that feels like contributing. If my former students walk over the threshold and the patient is glad to see them, we've done good. I think that's an important thing, and it's a privilege to be in that role.
As someone creating curricula and as an advocate, you've helped ensure that medical students are aware of cultural competency in terms of sex and gender education and providing care to diverse populations. What are some of the ways that you've taught that and why is that something that is near and dear to you?
Oh gosh, where do I even start? I think that sometimes it's easy, because you can think about early formation and things that influence you. I grew up in Altoona, Pennsylvania, and if you asked how many Hispanic families there were in Altoona: there was my family, there wasn't anybody else. If you asked how many Spanish speakers there were in Altoona: us. I lived in Central Pennsylvania as a kid, I was from Central Pennsylvania but at the same time, my family spoke Spanish and my first comprehension language is Spanish.
Being at least bi-cultural – and if you include LGBTQ, tri-cultural, and being a woman, quadri-cultural – in terms of living through the world, I think that presents a really interesting opportunity because you see things in ways that others may not.
When I went to medical school in Philadelphia at Hahnemann, suddenly I was "a Latina" and people were asking, "Can we interview you about what it was like growing up in the barrio?" I'd respond, "I'm from Altoona." They would laugh and I'd say, "Okay, so you've been to Altoona." I wasn't some sort of stereotype that they had in their mind. But it also helped.
In what ways was it helpful?
A powerful experience when I was a third-year clerk at another affiliate was in my first week of GYN. It was the same thing – the nurse says, "Núñez, you speak Spanish?" and I said, "Kind of." And she tells me about this patient who is 26 years old. She's Puerto Rican and she recently delivered her sixth baby. She had a fever when she delivered and the baby had been in the nursery.
The nurse said the mother was being a pain in the butt – basically, "Go calm her down." So I go to her room and introduce myself in my wonderful Spanglish, and she looks me straight in the eye and says, "I know what's going on. You people killed my baby. I know how this works: I'm pregnant, I come here, I have the baby and take the baby home. But this time, you all took my baby and you killed my baby." She hadn't seen her child for three days.
I explained, "No, no, no, your child has a cold," and took her over and showed her the baby, because no one else on the floor spoke anything but English. I thought, "We have to do better than this."
I had the opportunity during my medical education fellowship to do a topic of my choice, which is pretty unusual in fellowships. I did it in what was then called "diversity," which became "cultural competency," which has sort of morphed to "health disparities," which has turned into "health equities" in terms of moving things forward.
When I got into the position of being director for the Center of Excellence in Women's Health, one part of our work in the community was saying, "All women are the women we care about." Women's health historically had served a very skewed percentage of the population. It wasn't inclusive of all women, just some women.
At the Center of Excellence, I was able to acquire some grants for women living with HIV and for underserved women in the community, which changed up the status quo. The opportunity to get grant funding opened doors and we were able to say, "We need to serve all sort of folks, including patients' families and communities," and we also expanded from there to be more inclusive of gender and sexual minorities as well.
Addressing health inequities is so important, especially now when we're talking about health disparities and COVID-19.
Well, it brings up the issue that in the United States, we don't actually have a health care system. We have a health care financing system and we have a system that has been accepted for a very, very long time that inequities are just part of how things happen. I think it's about time that we start to see people addressing some of these things. You know, we've always had double-digit unemployment when you look at it as white versus non-white, and now people are taking notice. I think it exposes the fact that we've just become, for a long time, complacent that injustice is just what happens and there's nothing we can do about it. And I think what is impressive about right now is that people have said, "Wait, this isn't acceptable, and we really want to do something to change it." I think that's very exciting.
While we're talking about this moment in time – in June there was a major reduction in anti-discrimination protections for LGBTQ+ people seeking medical care, which experts say will especially impact transgender and nonbinary people. When we're talking about health inequities, can we talk a little bit about what work needs to be done in terms of the LGBTQ+ community?
It runs the gamut, because understandably we use the umbrella in terms of saying "LGBTQ," but I think that the needs of individuals within the community have different degrees. Certainly being discriminated against, problems with access, poor health – those are issues for many people under the LGBTQ+ umbrella, but I think that there is a range in terms of those issues. There's sadly active animus toward transgender people, and that's a piece of the pie. I think that's an important piece that has to be reconciled and acknowledged, and people have to be held accountable in terms of saying, "This is not acceptable, and we have to do something different."
We're at an interesting point for medicine when it comes to the gender continuum, because you have a lot of people in place – some of whom are relatively young – whose mindsets are circa 1950 and 1960 in terms of heteronormative thinking. And they have a hard time wrapping their minds around the existence of a gender continuum. So I think that there has to be significant training. For instance, in the state of Pennsylvania, you have to do certain CME hours on safety and risk reduction to keep your medical license. There are states that demand that a high-priority training area is cultural competency, which includes issues like this. I think mandating training in areas like this would be helpful because people tend to be very binary and reductionistic. And unfortunately, I think what happens most the time is that these are good-hearted, well-meaning people who are creating environments that don't feel safe and don't feel inclusive. There has been work in that space, but there needs to be continued work in that area so that people can align in terms of giving good care.
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